Predictive factors for treatment success of epidural steroid injections in patients with lumbar spinal surgery.

OBJECTIVE: The efficacy of epidural steroid injections (ESIs) in the treatment of radicular pain in patients undergoing lumbar spinal surgery is still unclear. The aim of this study was to investigate the factors affecting the success of ESIs in the treatment of ongoing radicular pain in patients undergoing lumbar spinal surgery. PATIENTS AND METHODS: This study was designed as a single-center, retrospective study, and was conducted at a Pain Management Center of a tertiary care center. A total of 260 patients with failed back surgery syndrome who received fluoroscopy-guided lumbar ESI were included. Treatment success was defined as ≥50% reduction in the numeric rating scale score at the one-month follow-up. The patients were divided into the treatment success and the treatment failure groups. RESULTS: The presence of spinal instrumentation was significantly lower in the treatment success group (p=0.045). Symptom duration and the numeric rating scale score at 1 hour were significantly lower in the treatment success group (p<0.05). The use of triamcinolone acetonide in the treatment success group was found to be significantly higher than in the treatment failure group (p=0.027). CONCLUSIONS: The short duration of symptoms and the absence of instrumentation seem to be prognostic factors that positively affect the success of ESI treatment in operated patients. A ≥50% pain reduction in the first hour after the procedure is a valuable indicator that treatment success can be achieved in the short term. Finally, the steroid type can also affect the treatment results.

Value of Examination Under Fluoroscopy for the Assessment of Sacroiliac Joint Dysfunction.

BACKGROUND: Pain emanating from the sacroiliac (SI) joint can have variable radiation patterns. Single physical examination tests for SI joint pain are inconsistent with multiple tests increasing both sensitivity and specificity. OBJECTIVE: To evaluate the use of fluoroscopy in the diagnosis of SI joint pain. STUDY DESIGN: Prospective double blind comparison study. SETTING: Pain clinic and radiology setting in urban Veterans Administration (VA) in New Orleans, Louisiana. METHODS: Twenty-two adult men, patients at a southeastern United States VA interventional pain clinic, presented with unilateral low back pain of more than 2 months' duration. Patients with previous back surgery were excluded from the study. Each patient was given a Gapping test, Patrick (FABERE) test, and Gaenslen test. A second blinded physician placed each patient prone under fluoroscopic guidance, asking each patient to point to the most painful area. Pain was provoked by applying pressure with the heel of the palm in that area to determine the point of maximum tenderness. The area was marked with a radio-opaque object and was placed on the mark with a fluoroscopic imgage. A site within 1 cm of the SI joint was considered as a positive test. This was followed by a diagnostic injection under fluoroscopy with 1 mL 2% lidocaine. A positive result was considered as more than 2 hours of greater than 75% reduction in pain. Then, in 2-3 days this was followed by a therapeutic injection under fluoroscopy with 1 mL 0.5% bupivacaine and 40 mg methylprednisolone. RESULTS: Each patient was reassessed after 6 weeks. The sensitivity and specificity in addition to the positive and negative predictive values were determined for both the conventional examinations, as well as the examination under fluoroscopy. Finally, a receiver operating characteristic (ROC) curve was constructed to evaluate test performance. The sensitivity and specificity of the fluoroscopic examination were 0.82 and 0.80 respectively; Positive predictive value and negative predictive value were 0.93 and 0.57 respectively. The area under ROC curve was 0.812 which is considered a "good" test; however the area under ROC for the conventional examination were between 0.52-0.58 which is considered "poor to fail". LIMITATIONS: Variation in anatomy of the SI joint, small sample size. CONCLUSIONS: Multiple structures of the SI joint complex can result in clinical symptoms of pain. These include intra-articular structures (degenerative arthritis, and inflammatory conditions) as well as extra-articular structures (ligaments, muscles, etc.).

Ankylosing spondylitis and a diagnostic dilemma: coccydynia.

OBJECTIVES: Coccydynia is defined as pain in or around the tail bone area. The most common cause of coccydynia is either a trauma such as a fall directly on to the coccyx or repetitive minor trauma. The etiology remains obscure in up to 30% of patients. The literature on the contribution of rheumatic diseases to coccydynia is scarce. Our objective was to investigate the prevalence of coccydynia in ankylosing spondylitis (AS) patients. METHODS: One hundred and seven consecutive patients with AS were evaluated for coccydynia were enrolled between January and November 2012 for a cross-sectional analysis. Seventy-four consecutive patients were followed for mechanical back pain as controls and the AS patients were interviewed for the presence of coccydynia. The data collected was evaluated on SPSS® version 11.5 and Microsoft Excel® Programmes. RESULTS: Prevalence of coccydynia in AS (38.3%) was significantly higher than the control group (p<0.0001) in both female and male AS patients (female AS vs. control=40.9% vs. 18.4%, p=0.015 and male AS vs. control=36.5% vs. 8.0%, p=0.005). Both genders were affected equally in the AS group whereas coccydynia was slightly more frequent in female patients in the control group. CONCLUSIONS: Coccydynia is a previously neglected symptom of AS and it is almost three times more common in AS than in non-specific chronic low back pain. Our observation may implicate that inflammatory diseases have a role in the etiology of coccydynia, especially in those without a history of recent or past trauma and coccydynia may be a factor associated with the severity of AS as well.

Depression and psychosocial factors in Turkish women with fibromyalgia syndrome.

AIM: The aim of this study was to evaluate the demographic qualifications, frequency of depression, degree of pain, and the correlations between these factors in Turkish women with fibromyalgia syndrome (FS). METHODS: Fifty-three women with FS and 54 healthy women were included in the study. The visual analogue scale (VAS) was applied to evaluate the degree of pain and Beck depression inventory (BDI) for depression. RESULTS: Mean age of the FS and the healthy women groups was 42.6+/-9.6 (21-63) and 39.4+/-13.2 (24-60) years respectively; which were statistically similar (P>0.05). Of the patients, 69.8% were married, and the mean years of education was 8.7+/-4.8 years. Marriage among relatives was found in 18.4% of the patients. The mean VAS score of the patients was 7.2+/-1.7 cm with the mean duration of pain 5+/-4.6 years. Mean BDI scores of FS patients and the healthy group were 15.7+/-8.7 and 10.2+/-5.5 respectively; the difference between the 2 groups was statistically significant (P<0.05). According to the BDI scores, 90% of FS patients were classified as depressed; among them, 50% had minor, 38% moderate, and 2% severe depression. FS patients who were married to a relative had higher scores of BDI (r=0.414, P=0.013). There was negative correlation between BDI score and patients' total year of education (r=-0.295, P=0.037); and the husband's education level (r=-0.367, P=0.030). According to BDI, the c2 test revealed significant depression in patients with sleep-disorders (P=0.009). CONCLUSIONS: We found a significant degree of depression in Turkish female FS patients. This situation is found to be correlated with the education level of both patient and husband; marital status, and sleep-disorder; it is suggested that these factors should be taken into consideration in the diagnosis, treatment and follow-up of FS patients.

Bone mineral density in patients with stroke.

OBJECTIVE: Stroke is an acute neurologic dysfunction of vascular origin, characterized by loss of voluntary movement, sensory disturbances, and neurologic findings in the contralateral half of the body. Acute and long-term complications because of immobilization are seen in all organ systems. The aim of this study was to determine any differences between the affected and unaffected sides' bone mineral densities of acute and chronic stroke patients. DESIGN: In this study, we determined the bone mineral densities (BMD) of 30 male patients with acute (0-20 days) and 30 male patients with chronic (6 months or longer) stroke and compared the densities with the normal side. Upper and lower limb BMDs were measured by dual-energy x-ray absorptiometry. Additionally, patients were evaluated for the degree of spasticity, the phases of motor improvement, and the activities of daily living. RESULTS: In acute-phase stroke patients, BMD of the affected side was not significantly different from BMD of the normal side. BMD of both upper limbs of acute stroke patients was not different from normal side upper limb BMD of chronic stroke patients. In both acute and chronic stroke patients, affected and unaffected side lower limb BMDs (femur total BMD scores) were not significantly different. However, in chronic stroke patients, affected side BMD of Ward's region was significantly higher compared with the normal side. There is no correlation between BMD and Brunnstrom phases, Ashworth scales, and the degree of activities of daily living. CONCLUSIONS: Higher BMD of the affected side Ward's region in chronic cerebrovascular accident patients may be related to spasticity and changes in walking pattern, which increase the mechanical stress loading of the Ward's region.

Systemic sclerosis with renal crisis and pulmonary hypertension: a report of eleven cases.

OBJECTIVE: To describe a series of systemic sclerosis (SSc) patients with the unusual combination of scleroderma renal crisis (SRC) and pulmonary hypertension (PHT) without interstitial lung disease. METHODS: The medical records of 2,459 SSc patients in the University of Pittsburgh Scleroderma Databank first evaluated between 1972 and 1999 were reviewed. RESULTS: Eleven patients (0.45%) had both SRC and PHT. All had been evaluated since 1979, when angiotensin-converting enzyme (ACE) inhibitor therapy for SRC became available. Seven had SSc with limited cutaneous involvement, and 4 had SSc with diffuse cutaneous involvement. SRC occurred first in all patients except 1, in whom the onsets of SRC and PHT were simultaneous. SRC preceded PHT by a mean of 4.3 years. Four patients had anti-Th/To antibody, 5 had anti-RNA polymerase III antibody, 2 had anti-U3 RNP antibody, and none had anticentromere or antitopoisomerase I antibody. Ten of the 11 patients died, 8 from PHT. Ten patients were being treated with ACE inhibitor drugs when PHT developed. CONCLUSION: In SSc, SRC and PHT are not mutually exclusive complications. SSc patients surviving SRC who have serum antibodies to Th/To, RNA polymerase III, or U3 RNP are at increased risk to develop PHT. ACE inhibitor therapy did not prevent the development of PHT.

Alendronate in rheumatoid arthritis patients treated with methotrexate and glucocorticoids.

Rheumatoid arthritis (RA) is a systemic inflammatory disease. Along with synovial joint inflammation, extra-articular involvement is a common feature of RA. Periarticular and generalized osteoporosis are seen both as an extra-articular feature of the disease itself and due to various medications like glucocorticoids and methotrexate (MTX). In this study, we investigated the effects of oral alendronate in RA patients treated with MTX and prednisolone by comparing the effects of "alendronate+calcium" and "only calcium" on bone mineral density (BMD). Fifty RA patients classified according to American Rheumatism Association (ARA) criteria were included in the study. The control group consisted of 20 postmenopausal osteoporotic patients. The RA patients were divided randomly into two groups. All patients were started on MTX 7.5 mg/week, 2.5-mg daily folic acid, and 7.5-mg daily prednisolone. The first group, consisting of 25 female RA patients, was also given 10-mg daily alendronate and 1000-mg daily calcium. The second group also consisted of 25 female patients and was given only 1000-mg calcium per day. The postmenopausal control group was given daily 10-mg alendronate and 1000-mg calcium. Bone mineral densities were measured by dual-energy x-ray absorptiometry (DEXA) and again at the end of the sixth month. At the end of the study, RA patients given only calcium had reduced mean BMD, and patients treated with alendronate and calcium showed increased mean BMD almost in all regions. This increase was significant in the L2 and L1-4 total regions. In postmenopausal osteoporotic patients, we saw statistically significant increases in BMD in all regions. The increase in BMD values in RA patients treated with alendronate was smaller than in those of the control group of postmenopausal osteoporosis patients. In conclusion, RA itself has a risk factor for osteoporosis in addition to the risks of the medications like corticosteroids and MTX. In the prevention and treatment of RA-associated osteoporosis, alendronate and calcium therapy is effective and well tolerated.

Reflex sympathetic dystrophy arising in a patient with familial Mediterranean fever.

A 14-year-old girl with familial Mediterranean fever (FMF) had had acute attacks of fever, abdominal pain, and arthritis for 4 years. Her last arthritis attack was protracted, leading to reflex sympathetic dystrophy (RSD) in her right lower extremity. Physical therapy along with sympathetic ganglion block and corticosteroid therapy was used for the treatment. To our knowledge, this is the first reported case of RSD arising in a patient with FMF. Early recognition of RSD in FMF patients is important, and physical therapy should be applied along with medical treatment.

Protracted familial Mediterranean fever arthritis.

Familial Mediterranean fever (FMF) is an inherited disorder characterized by recurrent attacks of fever and abdominal, chest, and articular pain. The articular attack of FMF is typically an acute, self-limited, large joint monoarthritis most often affecting the knee or hip. Rarely, a more protracted arthritis may occur. We describe two unusual cases of long-standing FMF arthritis with excellent response to synovectomy.