Lumbar Intradiscal Ozone Chemonucleolysis Applied Together with the Epidural Steroid Treatment.

OBJECTIVES: Intradiscal ozone treatment is a minimally-invasive method that can be applied to patients who have low back pain and do not respond to conservative treatment. This retrospectively designed study aimed to evaluate its clinical efficacy, adverse effects, or complication rates. METHODS: Patients with lumbar degenerative disc disease (LDDD) who underwent intradiscal O2-O3 treatment between January 2016 and April 2018 were included in the study. Pain and disability levels were assessed at pre-injection, 1-month and 1-year post-injection periods using visual analog scale (VAS) and Oswestry Disability Index (ODI), respectively. RESULTS: A total of 520 patients (270 males and 250 females) with the mean age of 38.9±5.7 years included in the study. First-month and 1st-year post-injection VAS and ODI scores were significantly lower than pre-injection scores (p<0.001). Remarkable VAS score reduction (more than 50%) was found in 60.2% of patients at 1st month and in 52.9% of patients at the 1st year. No important side effects recorded. CONCLUSION: Intradiscal ozone therapy applied together with the epidural steroid treatment, one of the percutaneous application techniques for the treatment of low back pain related to LDDD, has successful outcomes, clinical efficacy, and low rate of side effects, and thus, is one of the methods that should be considered before surgery when appropriate patients.

Role of paraspinal mapping before transforaminal epidural injections for lumbar radiculopathy.

OBJECTIVES: This study aims to investigate whether electromyography (EMG) including paraspinal mapping (PM) and specific clinical findings before the injection have a predictive role on the results in patients undergoing unilateral transforaminal epidural steroid injection (TFESI). PATIENTS AND METHODS: In this prospective study, a total of 46 patients (19 males, 17 females; mean age: 44.0±10.8 years; range, 23 to 60 years) with unilateral L5 root compression confirmed by physical examination, EMG and lumbar MRI between March 2013 and January 2014 were included. The patients underwent L5 TFESI. After the injection, they were examined at 1 h, three weeks, and three months. RESULTS: The clinical findings and presence of acute involvement on EMG were not predictive for TFESI results; however, the patients with lower scores for the L5 segment in PM benefited more from the injection, compared to patients with higher scores for the L5 segment in PM. CONCLUSION: In patients with very clearly defined L5 radiculopathy, PM EMG can give us an idea about the effectiveness of L5 TFESI.

Do informative leaflets affect pre-procedural anxiety and immediate pain after transforaminal epidural steroid injections? A prospective randomized controlled study.

OBJECTIVES: The aim of this study was to evaluate the effect of an informative leaflet provided to patients before a lumbar transforaminal epidural steroid injection (TFESI) on the level of immediate pain and pre-procedural anxiety. METHODS: A total of 166 patients were randomized into 2 groups: a group that received an explanatory leaflet (LG) and a control group. Both groups were given verbal information, while the LG was also given an illustrated leaflet describing the injection process. All of the patients were evaluated with the Hospital Anxiety and Depression Scale before the TFESI. The numerical rating scale and the Oswestry Disability Index (ODI) were used to assess disability and pain before and after the TFESI. Major complications that occurred before and during the procedure were recorded and analyzed. RESULTS: The patient characteristics were similar in both groups (age, body mass index, depression level, pre-procedural pain, and ODI). The anxiety level was also similar in both groups (p>0.05). When both groups were evaluated at the first hour after the procedure, the numerical rating scale level of pain intensity was also similar (p>0.05). No major complication was observed in either group. CONCLUSION: The detailed leaflet did not affect the patients' pre-procedural anxiety or acute post-procedural pain level. However, the importance of informed consent and comprehensive information should not be overlooked.

Efficacy of Intradiscal Ozone Therapy with or without Periforaminal Steroid Injection on Lumbar Disc Herniation: A Double-Blinded Controlled Study.

BACKGROUND: Intradiscal ozone therapy, a minimally invasive technique, is used in patients that do not respond to standard conservative therapies for low back pain due to degenerative disc-induced lumbar disc herniation (LDH). Many studies on clinical efficacy lack a standardized injection method and are limited by inadequate study design. OBJECTIVE: This study aimed to determine the efficacy of periforaminal steroid injection together with intradiscal ozone therapy. STUDY DESIGN: A prospective, double-blinded, randomized controlled trial. SETTING: A tertiary care center. METHODS: This study was conducted in 65 patients with low back and leg pain caused by LDH. Group 1 received intradiscal ozone therapy (n = 35) and Group 2 received intradiscal ozone therapy with periforaminal steroid injection (n = 30). Patients were evaluated for pain using the visual analogue scale (VAS), for disability using Oswestry Disability Index (ODI), and for quality of life using the short form 36 health survey administered pre-injection and at one and 6 months post-injection. All procedures were performed under sterile conditions using C-arm fluoroscopy. RESULTS: Significant improvements were observed in pain, disability, and quality of life in both groups post-treatment compared to pre-injection. Mean pre-injection VAS was not significantly different between the groups (VAS: 7.8 ± 1.1 for Group 1, 7.8 ± 1.2 for Group 2). VAS values at 6 months for Group 1 and Group 2 were as follows: 3.6 ± 2.4, 4.1 ± 1.6, respectively) (P < 0.001). Mean pre-injection ODI was not significantly different between the groups (ODI: 20.9 ± 9.6 for Group 1, 25.2 ± 10.3 for Group 2). ODI values at 6 months for Group 1 and Group 2 were as follows: 12.8 ± 9.2, 14.3 ± 7.2, respectively) (P < 0.001). However, there were no significant differences between the groups. Similarly, there was no significant difference between the 2 groups on any of these parameters. LIMITATIONS: A limited number of patients and limited follow-up time. CONCLUSION: This study showed that intradiscal ozone injection alone was sufficient to treat low back and leg pain caused by LDH and that periforaminal steroid injection does not provide additional benefit, which is contrary to the literature.

The Effect of Pre-Treatment Depression, Anxiety and Somatization Levels on Transforaminal Epidural Steroid Injection: A Prospective Observational Study.

BACKGROUND: Results of the lumbar transforaminal epidural steroid injection (L-TFESI) used in the treatment of lumbar radiculopathy may be affected by the current psychiatric condition of the patient. OBJECTIVES: The study aimed to assess the effects of pretreatment comorbid psychiatric conditions on patient outcomes in patients with lumbar disc herniation and radiculopathy. STUDY DESIGN: The study used a prospective-observational study design. SETTING: Research was conducted at a university hospital international pain management center. METHODS: In this observational study, 103 patients were included. All patients were evaluated with the Hospital Anxiety and Depression scale (HADS) for depression and anxiety levels and the Somatosensory Amplification Scale (SSAS) for somatization levels before the L-TFESI. The treatment results were evaluated with the Numeric Rating Scale (NRS) and the Oswestry Disability Index (ODI) at baseline, the third week, and the third month. Relative to baseline, a 50% reduction in the NRS was accepted as a successful treatment. RESULTS: HADS-depression, HADS-anxiety, and SSAS levels were similar between the patients with successful treatment outcome and the patients in whom treatment failed. However, there were negative correlations between percent reduction in the NRS and the HADS-depression levels at 3 weeks (r = -0.182, P = .022) and 3 months (r = -0.204, P = .037). Also, there were positive correlations between patients' pre-injection ODI scores and both the HADS-anxiety (r = 0.271, P = .001) and SSAS (r = 0.201, P = .013) scores. LIMITATIONS: The study was limited by a relatively short-term follow-up period. CONCLUSIONS: Although psychiatric conditions affected the pain and disability of patients before and after the L-TFESI, and may have an impact on patient-related outcomes, they should not be a reason to not treat patients or expect a lower chance of success. KEY WORDS: Anxiety, depression, disc herniation, low-back pain, lumbar radiculopathy, patient-related outcomes, somatization, transforaminal epidural steroid injection.

Effect of piriformis injection on neuropathic pain.

OBJECTIVES: The aim of this study was to investigate the effect of a piriformis injection on neuropathic pain in patients with piriformis syndrome. METHODS: Thirty patients with unilateral hip and/or leg pain, a positive FAIR test (increased H-reflex latency with Flexion, Adduction and Internal Rotation), and a trigger point at the piriformis muscle were enrolled in this prospective study. All of the patients exhibited neuropathic pain scored according to the Douleur Neuropathique 4 (DN4) of ≥4 for at least 6 months. All of the patients received 4 mL of lidocaine 2%+1 mL of betamethazone to the piriformis muscle under the guidance of ultrasound. The Numeric Rating Scale (NRS), DN4, and the painDETECT (PD) questionnaire were used for outcome assessment. RESULTS: A statistically significant improvement was seen in all scores (p<0.001) when both first week and first month results were compared with the baseline values. Comparison of the first week results with those of the first month revealed a statistically significant improvement in only the NRS and PD scores (p<0.001). The greatest improvement in all scores was seen in the first week after the injection. A mild increase was seen in all scores at the first month compared to the first week. CONCLUSION: A piriformis injection was found to be effective for both somatic and neuropathic pain in piriformis syndrome patients. Long-term follow-up is needed in order to consider this option alongside other treatment alternatives, like botulinum toxin and myofascial release.

Outcome measurement in patients with low back pain undergoing epidural steroid injection.

OBJECTIVES: This study aims to evaluate the outcomes of epidural steroid injection (ESI) in patients with low back pain. PATIENTS AND METHODS: This prospective study included a total of 82 patients (51 females; 31 males; mean age 50.8±14.2 years; range, 17 to 86 years) who underwent ESI due to lumbar disc hernia-induced radiculopathy between September 2014 and May 2015. The Numeric Rating Scale (NRS), Oswestry Disability Index (ODI), Istanbul Low Back Pain Disability Index (ILBPDI), and the Short Form-36 (SF-36) were administered to all patients before and three weeks and three months after ESI. RESULTS: The mean scores of all scales were significantly lower at three weeks and three months following ESI compared to the baseline scores. There were no significant differences between the mean scores at three weeks and three months. The NRS yielded the highest post-ESI change from baseline. CONCLUSION: Our study results showed that all scales used in this study were effective tools for the evaluation of outcomes of EPI in patients with low back pain. Although the NRS yielded the highest sensitivity for detecting change, evaluating functional state and quality of life is essential for multivariate analyses.

The Effect of Lumbar Spinal Surgery History on Intradiscal O2-O3 Treatment Results in Patients with Lumbar Disk Herniation.

OBJECTIVES: The aim of the present study was to investigate the effect of previous spinal surgery on intradiscal ozone-oxygen (O2-O3) treatment in low back pain associated with lumbar disc herniation (LDH). METHODS: Patients who underwent intradiscal O2-O3 therapy for LDH-induced low back pain were screened retrospectively from hospital records. To ensure homogenization of participants, patients who had received O2-O3 therapy to L4-L5 and L5-S1 intervertebral discs, those with pre-injection and post-injection month 1 data, and those who completed the first year of treatment were included in the study. Patients who completed the first year of treatment but with missing data were contacted and followed up by phone. Patients who underwent surgery at the same level as the injection level were classified as Group 1 (n=30), and those without surgery were classified as Group 2 (n=43). Pain and disability were measured by Visual Analog Scale (VAS) and Oswestry Disability Index (ODI), respectively. RESULTS: There was no statistically significant difference between the pre-injection VAS and ODI scores of the groups (p=0.719 and p=0.108). Group 1 had significantly higher VAS and ODI scores on month 1 and year 1 than Group 2, and statistically significant decreases were seen in VAS and ODI scores in both groups at follow-up (p<0.001 for all). There was no statistically significant difference between month 1 and year 1 VAS evaluations of the groups with respect to ≥50% improvement in pain reduction (p=0.213 and p=0.347). CONCLUSION: In the present study, the effect of the history of spinal surgery on intradiscal O2-O3 treatment results was investigated. Intradiscal injection was found to be effective for both groups, but more successful results were obtained in patients without surgical history.

Comparison of Epidural Steroid Injection Efficiency with Two Different Doses in Radiculopathies Associated with Lumbar Disc Herniation.

OBJECTIVE: Transforaminal epidural steroid injections (TFESIs) have been increasingly used in the treatment of lumbar radicular pain resistant to conservative modalities. Although different steroids can be used at different doses, the minimally effective steroid dose should be used to reduce side effects. The present retrospective study examined and compared the efficacy of 40 mg and 80 mg of methylprednisolone in TFESIs. METHODS: We included 67 patients who had undergone unilateral L5-S1 TFESIs under fluoroscopic guidance in the present study. Assessments were conducted at baseline and at 1 hour, 3 weeks, and 3 months after the TFESIs. The Short-Form 36-item Health Survey, Numeric Rating Scale, Oswestry Disability Index, and Istanbul Low Back Pain Disability Index were used as outcome measures. RESULTS: The present study evaluated 33 patients who had undergone TFESIs with 40 mg of methylprednisolone and 34 patients who had undergone TFESIs with 80 mg of methylprednisolone. Although no statistically significant differences were found between the 2 groups' outcome measures, both groups showed significant improvements in pain, disability, and quality of life at 3 weeks and 3 months after treatment. CONCLUSIONS: TFESIs with 40 mg and 80 mg are effective for the treatment of pain that results from lumbar disc herniation. They also positively affect patients' disability and quality of life. However, neither steroid dose was more efficient than the other dose. Therefore, we believe the smaller dose should be preferred to reduce the potential side effects of steroids.

Ganglion Impar block improves neuropathic pain in coccygodynia: A preliminary report.

AIM OF THE STUDY: To define the effectiveness of ganglion Impar block in improving neuropathic pain. MATERIALS AND METHODS: Patients who had pain around the coccyx for more than three months and did not respond to conservative treatment were included in this study. All the patients underwent fluoroscopy guided transsacrococcygeal ganglion Impar block with injecting 3 mL of 0.5% bupivacaine, 2 mL saline, and 1 mL (40 mg) of methylprednisolone. Patients were evaluated with visual analog scale (VAS) for pain, Leeds assessment of neuropathic symptoms and signs scale (LANSS) for neuropathic pain, Beck depression Inventory (BDI) for mood and Short-form 12 (SF-12) for quality of life before, 1 month 3 months and 6 months after the injection. Patients' painless sitting duration was also recorded. RESULTS: A total of 28 patients were included in the final analyses. VAS and LANSS scores improved significantly throughout the follow-up periods. BDI scores also improved while SF-12 scores did not show significant changes. Painless sitting period of the patients' improved significantly. CONCLUSIONS: Ganglion Impar block is effective in decreasing the neuropathic component of chronic coccygodynia. This improves painless sitting in patients but its reflections on quality of life is not clear.

The influence of coccygeal dynamic patterns on ganglion impar block treatment results in chronic coccygodynia.

Objective Ganglion impar block (GIB) can be performed in patients with chronic coccygodynia who do not respond to conservative treatments. We investigated the effect of coccygeal dynamic patterns on the treatment outcome in patients with chronic coccygodynia treated with GIB. Materials and methods We retrospectively analyzed the data for patients diagnosed with chronic coccygodynia who underwent GIB only once by a transsacrococcygeal method under fluoroscopy guidance in our Pain Medicine Clinic. Patients were assessed with standard and dynamic coccyx radiographs and classified according to coccygeal mobility. Pain scores were assessed with a numerical rating scale (NRS) before and after the intervention (at 1 hour and 4, 12 and 24 weeks). A 50% or more reduction in the NRS score was accepted as significant pain relief. Results Of the 37 patients included in the study, 14 had normal coccyx (Group I) and 23 had immobile coccyx (Group II) based on the radiological evaluation. The NRS scores were significantly reduced in both groups on each follow-up visit but there was no significant difference between the two groups in terms of pre- and post-intervention NRS scores. Significant pain relief was achieved in 42.9% and 61.9% of patients in Group I and II at the last examination, respectively. Conclusion GIB administered by transsacrococcygeal method in patients with chronic coccygodynia is a safe and alternative treatment approach with reduced pain scores and low complication rates. In patients with chronic coccygodynia, having a normal or immobile coccyx does not appear to affect treatment outcomes.

The efficacy of mirror therapy in patients with adhesive capsulitis: A randomized, prospective, controlled study.

OBJECTIVE: To investigate the effect of mirror therapy (MT) in conjunction with a standard physical therapy program on shoulder range of motion (ROM), pain and quality of life in patients with adhesive capsulitis (AC). METHOD: This prospective, randomized, controlled, single blind study included 30 patients with AC who were scheduled to undergo 10 sessions of standard physical therapy. The participants were divided into two identical groups, namely, The MT group and the control group. After each session, the MT group underwent active ROM exercises with the reflective side of the mirror while the control group underwent active ROM exercises with the non-reflective side of the mirror. Pre-treatment and post-treatment shoulder pain (VAS), shoulder function (UCLA shoulder scale) and quality of life (SF-36) were assessed, and active and passive ROM were quantified with a goniometer. RESULTS: Both groups revealed a significant reduction of shoulder pain and significant improvement of shoulder function, active and passive ROM, and quality of life after the treatment. Post-treatment measurements showed that the MT group had a significantly lower amount of pain compared to the control group (p= 0.007). The UCLA scores were significantly higher in the MT group (p= 0.003). The MT group had significantly better post-treatment active flexion, active abduction, passive flexion, and passive abduction values (p= 0.001, p= 0.02, p= 0.002, and p= 0.02, respectively). The MT group had significant post-treatment improvement in physical function, physical role limitation and emotional role limitation, and pain parameters including SF-36 (p= 0.003, p= 0.01, p= 0.015, and p= 0.002, respectively). CONCLUSION: MT in conjunction with physical therapy appears to be an effective treatment modality that reduces shoulder pain and improves shoulder ROM, shoulder function, and quality of life among patients with AC.

Cutaneous silent period in myofascial pain syndrome.

INTRODUCTION: An increased response to painful stimuli without spontaneous pain suggests a role of central hyperexcitability of pain pathways in the pathogenesis of myofascial pain syndrome (MPS). In this study we aimed to test the hypothesis that spinal pain pathways are affected in MPS. We used cutaneous silent period (CSP) parameters to demonstrate the hyperexcitability of spinal pain pathways in MPS. METHODS: Twenty-nine patients diagnosed with MPS and 30 healthy volunteers were included in the study. The CSP recordings were performed in the right upper and left lower extremities. RESULTS: In both upper and lower extremities, patients had prolonged CSP latencies (P = 0.034 and P = 0.049 respectively) and shortened CSP durations (P = 0.009 and P = 0.008, respectively). DISCUSSION: Delayed and shortened CSP in MPS patients implies dysfunction in the inhibitory mechanism of the spinal/supraspinal pain pathways, suggesting central sensitization in the pathogenesis of MPS and supporting our research hypothesis. Muscle Nerve 57: E24-E28, 2018.

A rare cause of thigh pain: Morel-lavallée lesion.

Morel-Lavallée lesion is an unusual clinical entity which was first described by the French surgeon Maurice Morel-Lavallée in 1853. These lesions result from peeling off the surfaces between the fat tissue and the muscular fascia. During this decomposition, the rupture of small vessels may cause an effusion full of necrotic blood, lymph and fat cells. In prolonged cases, these lesions may become increasingly painful, leading to be confused with other diagnosis such as sciatalgia, piriformis syndrome, trochanteric bursitis or soft tissue tumor. Herein, we present a-65-year-old female case who had pain in the right thigh for one year and was referred to our clinic with radicular pain.

Is fluoroscopy-guided percutaneous rupture of facet cyst an alternative to surgery? A case report.

Lumbar intraspinal synovial cysts (LISCs) are rare cause of the lumbosacral radicular syndrome. Fluoroscopy-guided percutaneous cyst rupture (PCR) is an option in the treatment. This report introduces long-term symptom relief after fluoroscopy-guided PCR of LISC. A 73-year-old patient presented with low back pain radiating to right leg. L5 radiculopathy was suspected by physical examination; however, an intraspinal cystic mass was visualized through imaging studies. The patient reported immediate pain relief after fluoroscopy-guided PCR, which sustained for one year. In conclusion, fluoroscopy-guided PCR appears to be a safe and effective treatment option and should be considered before surgery in patients with LISCs.