Does the location of low back pain predict its source?

OBJECTIVE: To evaluate the predictive utility of the pattern of low back pain (LBP) in detecting the source of LBP as internal disk disruption (IDD), facet joint pain (FJP), or sacroiliac joint pain (SIJP). DESIGN: Retrospective chart review. SETTING: University spine center. PATIENT SAMPLE: A total of 170 cases from 156 patients presenting with LBP whose low back disorder was definitively diagnosed. The mean age was 54.4 years (SD, 16.2) and median duration of LBP was 12 months (interquartile ranges, 6-32). METHODS: Charts of consecutive LBP patients who underwent definitive diagnostic spinal procedures including provocation diskography, facet joint blocks, and sacroiliac joint blocks were retrospectively reviewed. Each patient with LBP was queried as to the exact location of their LBP: midline, defined as in-line with the spinous processes, and/or paramidline, defined as lateral to 1 fingerbreadth adjacent to the midline. OUTCOME MEASURES: In patients with a definitive diagnosis for the source of LBP, the proportion of each diagnosed source of pain was calculated. χ(2) tests were used to identify differences in the percentages of midline and paramidline LBP among the groups of patients testing positive for IDD, FJP, or SIJP. Diagnostic measures of sensitivity, specificity, positive and negative predictive values, diagnostic accuracy, and likelihood ratios of positive and negative tests using the presence/absence of midline and paramidline pain for the diagnosis of IDD, FJP, and SIJP were estimated. RESULTS: With cases of IDD, significantly greater percentages of patients reported midline LBP (95.8%; χ(2) = 101.4, df = 2, P < .0001) as compared with cases of FJP (15.4%) or SIJP (12.9%). In cases of IDD, significantly lower percentages of patients reported paramidline pain (67.3%; χ(2) = 16.1, df = 2, P = .0003) as compared with cases of FJP (95.0%) or SIJ (96.0%). In cases of IDD, significantly greater percentages of patients reported midline LBP (95.8%; χ(2) = 101.4, df = 2, P < .0001) as compared with cases of FJP (15.4%) or SIJP (12.9%). The specificity of midline LBP for IDD, FJP, and SIJP was 74.8% (95% CI = 65.0%-82.9%), 28.0% (20.1%-37.0%), and 36.0% (28.0%-44.5%), respectively. The negative predictive value of paramidline LBP for IDD, FJP, and SIJP was 29.2% (95% CI = 12.6%-51.1%), 91.7% (73.0%-99.0%), and 95.8% (78.9%-99.9%). The diagnostic accuracy of midline LBP for IDD, FJP, and SIJP was 83.5%, 24.1%, and 31.8%, respectively. CONCLUSIONS: The presence of midline LBP increases the probability of lumbar IDD and reduces the probability of symptomatic FJ and SIJ dysfunction. The presence of isolated paramidline LBP increases the probability of symptomatic FJ or SIJ but mildly reduces the likelihood of lumbar IDD.

Evidence-informed management of chronic low back pain with epidural steroid injections.

The management of chronic low back pain (CLBP) has proven very challenging in North America, as evidenced by its mounting socioeconomic burden. Choosing amongst available nonsurgical therapies can be overwhelming for many stakeholders, including patients, health providers, policy makers, and third-party payers. Although all parties share a common goal and wish to use limited health-care resources to support interventions most likely to result in clinically meaningful improvements, there is often uncertainty about the most appropriate intervention for a particular patient. To help understand and evaluate the various commonly used nonsurgical approaches to chronic low back pain, the North American Spine Society has sponsored this special focus issue of The Spine Journal, titled Evidence-Informed Management of Chronic Low Back Pain Without Surgery. Articles in this special focus issue were contributed by leading spine practitioners and researchers, who were invited to summarize the best available evidence for a particular intervention and encouraged to make this information accessible to nonexperts. Each of the articles contains five sections (description, theory, evidence of efficacy, harms, and summary) with common subheadings to facilitate comparison across the 24 different interventions profiled in this special focus issue, blending narrative and systematic review methodology as deemed appropriate by the authors. It is hoped that articles in this special focus issue will be informative and aid in decision making for the many stakeholders evaluating nonsurgical interventions for CLBP.

Sacral stress fractures.

Sacral stress fractures are a relatively common occurrence and can be a debilitating source of low back pain. They generally occur in two distinctly different patient populations, and are of two different etiologies. Sacral insufficiency-type fractures are seen in elderly osteoporotic persons, and fatigue fractures are seen young active individuals. Although the clinical presentation of these fractures is similar, medical rehabilitation and interventional spine management strategies differ according to etiology. Although conservative management strategies have resulted in good outcomes, other treatment options have recently developed. This article provides an overview of the clinical presentation, pathology, and treatment options for sacral stress fractures and discusses some of the recent literature surrounding this interesting topic.

Side effects and complications after percutaneous disc decompression using coblation technology.

OBJECTIVE: To report the short-term side effects and complications after percutaneous disc decompression utilizing coblation technology. DESIGN: Following institutional review board approval, consecutive patients who were to undergo percutaneous disc decompression using coblation technology (nucleoplasty) were prospectively enrolled. Patients were questioned preoperatively, postoperatively, and 24 hrs, 72 hrs, 1 wk, and 2 wks postprocedure by an independent reviewer regarding 17 possible symptom complications, which included bowel or bladder symptoms, muscle spasm, new pain, numbness/tingling or weakness, fevers/chills, rash/pruritus, headaches, nausea/vomiting, bleeding, and needle insertion site soreness. Statistical analysis was performed using Wilcoxon's signed-rank test. RESULTS: A total of 53 patients enrolled, of whom four patients dropped out. Two patients had increased symptoms and opted for surgery. Two patients could not be contacted. The most common side effects at 24 hrs postprocedure was soreness at the needle insertion site (76%), new numbness and tingling (26%), increased intensity of preprocedure back pain (15%), and new areas of back pain (15%). At 2 wks, no patient had soreness at the needle insertion site or new areas of back pain; however, new numbness and tingling was present in 15% of patients. Two patients (4%) had increased intensity of preprocedure back pain. There were statistically significant reductions in visual analog scale score for back pain and leg pain (P < 0.05). CONCLUSIONS: Based on this preliminary data, nucleoplasty seems to be associated with short-term increased pain at the needle insertion site and increased preprocedure back pain and tingling numbness but without other side effects.

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.

Provocative cervical discography symptom mapping.

BACKGROUND CONTEXT: In a small prospective study assessing 10 symptomatic and 10 asymptomatic subjects, Schellhas et al. compared cervical discography to magnetic resonance imaging. Within that study he reported on the distribution of pain for the C3-C4 to C6-C7 levels. Four years later, Grubb and Ellis reported retrospective data from his 12-year experience using cervical discography from C2-C3 to C7-T1 in 173 patients. To date, no large prospective study defining pain referral patterns for each cervical disc has been performed. PURPOSE: To conduct a prospective visual and statistical descriptive study of pain provocation of a cohort of subjects undergoing cervical discography. STUDY DESIGN/SETTING: Prospective multicenter descriptive study. METHODS: Pain referral maps were generated for each disc level from patients undergoing cervical discography with at least two levels assessed. If concordant pain was reproduced in a morphologically abnormal disc, the subject immediately completed a pain diagram. An independent observer interviewed the subject and recorded the location of provoked symptoms. Visual data were compiled using a body sector bit map, which consisted of 48 clinically relevant body regions. Visual maps with graduated color codes and frequencies of symptom location at each cervical disc level were generated. RESULTS: A total of 101 symptom provocation maps were recorded during cervical discography on 41 subjects. There were 10 at C2-C3, 19 at C3-C4, 27 at C4-C5, 27 at C5-C6, 16 at C6-C7 and 2 at C7-T1. Predominantly unilateral symptoms were provoked just as often as bilateral symptoms. The C2-C3 disc referred pain to the neck, subocciput and face. The C3-C4 disc referred pain to the neck, subocciput, trapezius, anterior neck, face, shoulder, interscapular and limb. The C4-C5 disc referred pain to the neck, shoulder, interscapular, trapezius, extremity, face, chest and subocciput. The C5-C6 disc referred pain to the neck, trapezius, interscapular, suboccipital, anterior neck, chest and face. The C6-C7 disc referred pain to the neck, interscapular, trapezius, shoulder, extremity and subocciput. At C7-T1 we produced neck and interscapular pain. Visual maps with graduated color codes and frequencies of symptom location at each cervical disc level were generated. CONCLUSIONS: In conclusion, these results confirm the observations of prior investigators that cervical internal disc disruption can elicit axial and peripheral symptoms. The particular patterns of pain generation allow the discographer to preprocedurally anticipate disc levels to assess. With these data, the number of disc punctures that are required can be limited rather than routinely assessing all cervical discs.

A critical appraisal of the evidence for selective nerve root injection in the treatment of lumbosacral radiculopathy.

OBJECTIVE: To critically review the best available trials of the utility of transforaminal epidural steroid injections (TFESIs) or selective nerve root blocks (SNRBs) to treat lumbosacral radiculopathy. DATA SOURCES: MEDLINE (PubMed, Ovid, MDConsult), EMBASE, and the Cochrane database. Databases were searched from inception through 2003. STUDY SELECTION: A database search was conducted by using the following key words: prospective , transforaminal and foraminal epidural steroid injections , selective nerve root block and injection , and periradicular and nerve root injection . We included English-language, prospective, randomized studies of patients with lower-limb radicular symptoms treated with fluoroscopically guided nerve root or transforaminal epidural injections. DATA EXTRACTION: Data were compiled for each of the following categories: inclusion criteria, randomization protocol, total number of subjects enrolled initially and at final analysis, statistical analysis utilized, documentation of technique, outcome measures, follow-up intervals and results (positive or negative), and reported complications. These data were abstracted by 1 reviewer and reviewed by a second. Study quality was assessed with the system developed by the Agency for Health Care and Policy Research. DATA SYNTHESIS: We selected 6 articles for review. Our analysis identified a single article as the highest quality study addressing the appropriate use of TFESIs or therapeutic SNRBs. Coupled with the evidence provided by 4 other articles (1 article was excluded because its patients were not truly randomized), our review of the evidence for TFESIs found level III (moderate) evidence in support of these minimally invasive and safe procedures in treating painful radicular symptoms. However, conclusive evidence (level I) is lacking. CONCLUSIONS: The evidence for TFESIs reveals level III (moderate) evidence in support of these minimally invasive and safe procedures in treating painful lumbar radicular symptoms. Current studies support use of TFESIs as a safe and minimally invasive adjunct treatment for lumbar radicular symptoms. However, more prospective, randomized, placebo-controlled studies using sham procedures are needed to provide conclusive evidence for the efficacy of TFESIs in treating lumbar radicular symptoms.

Intradiscal electrothermal annuloplasty.

Low back pain is a common problem, and although the majority of cases of low back pain resolve, a subset of patients will continue to have intractable pain despite appropriate conservative treatments. Intradiscal electrothermal annuloplasty is a minimally invasive spinal procedure that has been proposed to treat provocation discography-proven internal disk disruption syndrome. The early uncontrolled and nonrandomized intradiscal electrothermal annuloplasty literature suggests it may provide some relief in a small proportion of strictly defined patients; however, more recent randomized, placebo-controlled trials have not substantiated these initial findings. This article will review the published literature, indications, contraindications, safety, and efficacy of the intradiscal electrothermal annuloplasty procedure for the treatment of chronic, intractable, axial back pain.

Dysphonia associated with shoulder steroid injection.

Glucocorticosteroid injections into the shoulder are commonly used in the treatment of rotator cuff tendinitis. These injections rarely result in any serious complications and are generally considered a safe therapeutic intervention. Despite the extensive application of this treatment, there have been no reports of dysphonia occurring after corticosteroid injection into the subacromial space. We report the case of a 66-yr-old man with dysphonia after undergoing subacromial glucocorticosteroid injection for treatment of rotator cuff tendinitis.

Complications and side effects of cervical and lumbosacral selective nerve root injections.

OBJECTIVE: To determine the incidence of complications and side effects of cervical and lumbosacral selective nerve root injections (SNRIs). DESIGN: Prospective, nonrandomized controlled trial of consecutive patients with independent interviews for immediate, 1-week, and 3-month follow-ups. SETTING: Tertiary, academic spine center. PARTICIPANTS: Of 160 patients eligible for SNRI, 151 underwent 306 SNRIs (study group). Sixty patients who had not undergone any intervention served as the control group. INTERVENTIONS: Diagnostic and therapeutic fluoroscopically guided cervical and lumbosacral SNRIs. Lidocaine (Xylocaine) was used in the diagnostic injections and a mixture of lidocaine and betamethasone was used in the therapeutic injections. MAIN OUTCOME MEASURES: Complications and side effects experienced during the procedure were recorded by the interventionalist. Side effects and complications experienced immediately, 1 week, and 3 months after injection were determined through independent interviews using a questionnaire format. The control group was independently interviewed using the same questionnaire. RESULTS: There were no major complications, such as death, paralysis, spinal nerve injury, infection, or allergic reaction, during the study. Ninety-one percent of subjects had no side effects during the procedure. A positive response on interview was reported by 39.4% of the study subjects immediately after the procedure. Lumbosacral SNRI side effects were as follows: increased pain at the injection site (17.1%); increased radicular pain (8.8%); lightheadedness (6.5%); increased spine pain (5.1%); nausea (3.7%); nonspecific headache (1.4%); and vomiting (0.5%). Immediate side effects from cervical SNRI were as follows: increased pain at injection site (22.7%); increased radicular pain (18.2%); lightheadedness (13.6%); increased spine pain (9.1%); nonspecific headache (4.5%); and nausea (3.4%). At the 1-week interview, comparison of the study and control groups showed statistical significance for the following: pain at injection site, cervical ( P =.001) and lumbar ( P =.005); nonspecific headache, cervical ( P =.019); and nonspinal headache, cervical ( P =.002). At 3 months, 2 subjects complained of increased neck pain and 1 reported heartburn and fluid retention. Two lumbar SNRI subjects were lost to follow-up. CONCLUSIONS: There were no major complications with cervical and lumbosacral SNRIs, although various minor side effects occurred.

Transforaminal cervical blood patch for the treatment of post-dural puncture headache.

A 40-yr-old woman received a series of three interlaminar epidural steroid injections for the treatment of axial neck pain secondary to degenerative disc disease. Immediately after her third injection, she experienced symptoms of a dural puncture-induced headache. This headache persisted on a daily basis for 3 mos, despite two epidural blood patches using an interlaminar approach, which was finally completely abated with a transforaminal blood patch. The headache was immediately relieved and remained alleviated through the follow-up interval of 1 yr. In this patient, a fluoroscopically guided transforaminal epidural blood patch proved to be more effective than the classic blind interlaminar approach in the treatment of post-dural puncture headache.

Therapeutic selective nerve root block in the nonsurgical treatment of traumatically induced cervical spondylotic radicular pain.

OBJECTIVE: To investigate the outcomes resulting from the use of fluoroscopically guided therapeutic selective nerve root block in the nonsurgical treatment of traumatically induced cervical spondylotic radicular pain. DESIGN: Retrospective study with independent clinical review. A total of 15 patients who met specific physical examination or electrodiagnostic criteria and failed to improve clinically after at least 4 wks of physical therapy were included. Each patient demonstrated a positive response to a fluoroscopically guided cervical selective nerve root block. Therapeutic selective nerve root blocks were administered in conjunction with physical therapy. Outcome measures included visual analog scale pain scores, employment status, medication usage, and patient satisfaction. RESULTS: Patients' symptom duration before diagnostic injection averaged 13.0 mos. An average of 3.7 therapeutic injections were administered. Follow-up data collection transpired at an average of 20.7 mos after discharge from treatment. An overall good or excellent outcome was observed in three patients (20.0%). Among those treated without surgery, a significant reduction (P = 0.0313) in pain score was observed at the time of follow-up. Six patients (40.0%) proceeded to surgery. CONCLUSIONS: These initial and preliminary findings do not support the use of therapeutic selective nerve root block in the treatment of this challenging patient population with traumatically induced spondylotic radicular pain.

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.

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.

Sacral stress fracture in a female field hockey player.

We report a collegiate field hockey player who sustained a sacral fatigue-type stress fracture that manifested as persistent low back and leg pain. The diagnosis of sacral stress fracture was suggested by history and physical examination and confirmed by magnetic resonance imaging. Our patient experienced complete resolution of symptoms after a 3-mo interval of activity restriction. This article describes the first reported case of a sacral stress fracture in a field hockey player.

Epidemiology of spine tumors presenting to musculoskeletal physiatrists.

OBJECTIVE: To report the incidence and epidemiologic formation of previously undetected primary and secondary spine tumors presenting as spinal and/or extremity pain to a physiatrist practicing in an academic or private practice multidisciplinary spine center. DESIGN: Multicenter retrospective chart review. SETTING: Three multidisciplinary spine settings (1 academic, 2 private). PARTICIPANTS: Charts of patients from 33 academic and 18 private practice settings. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Epidemiologic data collected included incidence, age, gender, race, and duration of symptoms before initial presentation. Symptom presentation data collected included intensity of pain when supine, sitting, standing, or walking; character of the pain; pain intensity as measured on the visual analog scale (VAS); spontaneous versus traumatic etiology; unexplained weight loss; presence of night pain; and fever. In addition, the results of radiographic studies including plain films, imaging, bone scan, and magnetic resonance imaging were recorded. The type of neoplastic disease was also assessed, primary versus metastatic, as well as the metastatic source. RESULTS: The incidence of spine tumors was.69% in academic multidisciplinary spine centers and.12% in private practice multidisciplinary spine centers. Patients with spinal pain because of neoplastic disease who presented to musculoskeletal physiatrists were an average age of 65.3 years and reported a relatively high likelihood of night pain, aching character of symptom manifestation, spontaneous onset of symptoms, history of cancer, standing and walking provoking symptoms, and unexplained weight loss. In addition, the pain intensity level ranged widely, with an average VAS score of 6.8. CONCLUSIONS: There are many similarities and differences in the clinical presentation of patients with spinal pain from spine tumors who present to musculoskeletal physiatrists practicing in multidisciplinary spine centers when compared with those presenting to a primary care setting.