Basivertebral Nerve Radiofrequency Ablation (Intracept): Procedural Technique.

Intraosseous basivertebral nerve ablation is indicated for the treatment of chronic vertebrogenic low back pain with failure of at least 6 months of conservative treatment. This article details patient positioning and setup, step-by-step instructions for the procedure, and postoperative management. Pearls and pitfalls are also discussed. In addition, an instructional procedure video accompanies this paper and can be found online (at https://vimeo.com/791578426/de0e90cfbe).

Preoperative Opioid Prescribers and Lumbar Fusion: Their Effect on Clinical Outcomes and Postoperative Opioid Usage.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: To determine the impact of multiple preoperative opioid prescribers on postoperative patient opioid usage and patient-reported outcome measures after single-level lumbar fusion. SUMMARY OF BACKGROUND DATA: Prior literature has identified opioid prescriptions from multiple postoperative providers increase opioid usage rates. However, there is limited evidence on how multiple preoperative opioid prescribers affect postoperative opioid usage or clinical outcomes after a single-level lumbar fusion. PATIENTS AND METHODS: A retrospective review of single-level transforaminal lumbar interbody fusion or posterolateral lumbar fusions between September 2017 and February 2020 at a single academic institution was performed. Patients were excluded if they were not identifiable in our state's prescription drug-monitoring program. Univariate comparisons and regression analyses identified factors associated with postoperative clinical outcomes and opioid usage. RESULTS: Of 239 patients, 160 (66.9%) had one or fewer preoperative prescribers and 79 (33.1%) had >1 prescribers. On regression analysis, the presence of multiple preoperative prescribers was an independent predictor of increased improvement in Visual Analog Scale (∆VAS) Back (ß=-1.61, P =0.012) and the involvement of a nonoperative spine provider was an independent predictor of increased improvement in ∆VAS Leg (ß = -1.53, P = 0.034). Multiple preoperative opioid prescribers correlated with an increase in opioid prescriptions postoperatively (ß = 0.26, P = 0.014), but it did not significantly affect the amount of morphine milligram equivalents prescribed (ß = -48.79, P = 0.146). A greater number of preoperative opioid prescriptions predicted worse improvements in VAS Back, VAS Leg, and Oswestry Disability Index and predicted increased postoperative opioid prescriptions, prescribers, and morphine milligram equivalents. CONCLUSIONS: Multiple preoperative opioid prescribers predicted increased improvement in postoperative back pain, whereas preoperative involvement of a nonoperative spine provider predicted improvements in leg pain after surgery. The number of preoperative opioid prescriptions was a better metric for predicting poor postoperative outcomes and increased opioid consumption compared with the number of preoperative opioid prescribers.

The Fluoroscopic-Guided Cervical Transarticular Epidural Steroid Injection.

ABSTRACT: The epidural space is commonly accessed via an interlaminar or transforaminal approach to administer corticosteroids for radicular pain. An alternative is a transarticular approach, which may be considered when conventional access to the epidural space is either not desired or contraindicated. This approach has been described in the cervical spine using computed tomography guidance but not fluoroscopic guidance. We describe a cervical transarticular approach to the epidural space under fluoroscopy and review the computed tomography-guided literature. The risks of transarticular epidural injections are likely low given that when performed prudently, they avoid direct contact with the vertebral artery, spinal medullary arteries, venous plexus, spinal cord, and nerve roots.

The Use of Cannabidiol in Patients With Low Back Pain Caused by Lumbar Spinal Stenosis: An Observational Study.

Background Spinal stenosis is a degenerative narrowing of the spinal canal with encroachment on the neural structures by surrounding bone and soft tissue. This chronic low back condition can cause restrictions in mobility, impairment of daily activities, opioid dependence, anxiety, depression, and reduced quality of life. Spinal stenosis can be treated through surgical and nonsurgical methods, but neither has proven consistently reliable. Cannabidiol (CBD) has also been observed to have anxiolytic, anti-inflammatory, antiemetic, and antipsychotic behaviors. CBD may provide greater nonsurgical treatment options for the pain associated with spinal stenosis while minimizing the need for opioids. An observational study was undertaken to assess the effects of CBD on patients suffering from chronic spinal stenosis. Methodology This observational study was investigator-initiated and designed to determine the effect of hemp-derived CBD gel caps for patients with spinal stenosis related to low back pain and leg pain relative to patient outcomes, medication utilization, and quality of life outcome measures. A total of six physician visits would be required where a set of surveys would be filled out each four weeks apart. Results The study population consisted of 48 patients. The patient population's age ranged from 63 to 95 years and was normally distributed, with a mean age of 75 ± 7.13 years. The sex distribution was 33% male and 67% female patients. The pain was broken down between the six visits for each of the following four questions: pain right now, usual pain level during the week, best pain level during the week, and worst pain level during the week. Usual pain levels (p < 0.001) and worst pain levels (p < 0.005) demonstrated statistically significant improvement over time, while pain right now (p > 0.05) and best pain level (p > 0.05) stayed consistent throughout without statistical significance. Conclusions This open-label, prospective, observational study found that treatment with hemp-derived CBD gel caps was associated with significant improvements in pain scores and several quality-of-life measures for patients with lumbar spinal stenosis.

Perspectives of Orthopedic Patients on Medical Cannabis: A Survey of More Than 2500 Patients.

Nationwide perspectives on cannabis have changed dramatically over recent decades. Although cannabis remains illegal at the federal level, medical cannabis (MC) is now legal in most states, and research has continued to show its effectiveness in a variety of medical conditions. However, both perception and acceptance of MC by the general public are evolving and remain poorly understood. Treating patients effectively with these novel therapeutics requires an understanding of the complex interplay of social and legal factors that could affect patient use. This cross-sectional survey study of more than 2500 patients sought to assess current patient perspectives on MC and to investigate factors related to its use that may represent barriers to broader patient use. Most respondents would consider using MC for chronic pain or other medical conditions. Most respondents were aware of the legal status of MC in their state, and 9 of 10 respondents believed that MC should be legal throughout the United States. General public knowledge of the utility of MC is an area needing improvement because older patients were significantly less likely to believe that MC is safe to use or that MC is safer than prescription opioids. As has been reported in previous literature, social stigma and cost appear to remain barriers for patient use of MC. Our findings provide further insight into current patient perspectives on MC, aiding both medical providers and researchers as we continue to provide access to and research MC. [Orthopedics. 2022;45(6):e309-e314.].

Thoracolumbar Spinal Cord Stimulator Trial: Procedural Technique.

Spinal cord stimulator trials are indicated for the treatment of postlaminectomy syndrome with persistent severe back and limb pain which has failed conservative treatment options and where no further surgery is indicated. They are also indicated for refractory complex regional pain syndrome. This article details patient positioning and set up, step-by-step instructions for the procedure and postoperative management. Pearls and pitfalls are also discussed. In addition, an instructional procedure video, Supplemental Digital Content 1 (http://links.lww.com/CLINSPINE/A121) accompanies this paper.

Spinal ganglion cyst presenting with radiculopathy: diagnostic challenges and differential.

INTRODUCTION: Ganglion cysts are benign soft tissue lesions, usually arising from periarticular connective tissue. These are very rarely reported in the spine, but when seen can cause radiculopathy or myelopathy. CASE PRESENTATION: A 68-year-old female patient presented with worsening radiculopathy and right foot drop and imaging noted a right L5-S1 foraminal mass. The lesion was gross totally resected. Histological analysis revealed myxoid degeneration and inflammation, without a synovial lining, consistent with ganglion cyst. DISCUSSION: While uncommon, intra-foraminal ganglion cysts can be distinguished from synovial cysts through imaging and histology and are typically amenable to surgical resection. Greater knowledge and insight about differentiating ganglion versus synovial cyst may prevent resection of facet joints and prevent a fusion procedure.

Differential rates of intravascular uptake and pain perception during lumbosacral epidural injection among adults using a 22-gauge needle versus 25-gauge needle: a randomized clinical trial.

BACKGROUND: Inadvertent intravascular injection has been suggested as the most probable mechanism behind serious neurological complications during transforaminal epidural steroid injections. Authors believe a smaller gauge needle may lead to less intravascular uptake and less pain. Theoretically, there is less chance for a smaller gauge needle to encounter a blood vessel during an injection compared to a larger gauge needle. Studies have also shown smaller gauge needle to cause less pain. The aim of the study was to quantify the difference between a 22-gauge needle and 25-gauge needle during lumbosacral transforaminal epidural steroid injection in regards to intravascular uptake and pain perception. METHODS: This was a prospective single blind randomized clinical trial performed at outpatient spine practice locations of two academic institutions. One hundred sixty-two consecutive patients undergoing lumbosacral transforaminal epidural injections from February 2018 to June 2019 were recruited and randomized to each arm of the study - 84 patients were randomized to the 22-gauge needle arm and 78 patients to 25-gauge arm. Each transforaminal injection level was considered a separate incidence, hence total number of incidence was 249 (136 in 22-gauge arm and 113 in 25-gauge arm). The primary outcome measure was intravascular uptake during live fluoroscopy and/or blood aspiration. The secondary outcome measure was patient reported pain during the procedure on the numerical rating scale. RESULTS: Fisher exact test was used to detect differences between 2 groups in regards to intravascular uptake and paired t-tests were used to detect differences in pain scores. The incidence of intravascular uptake for a 22-gauge needle was 5.9% (95% confidence interval: 1.9 to 9.8%) and for a 25-gauge needle, 7.1% (95% confidence interval: 2.4 to 11.8%) [p = 0.701]. Average numerical rating scale scores during the initial needle entry for 22-gauge and 25-gauge needle was 3.46 (95% confidence interval: 2.94 to 3.98) and 3.13 (95% confidence interval: 2.57 to 3.69) respectively [p = 0.375]. CONCLUSIONS: The study showed no statistically significant difference in intravascular uptake or pain perception between a 22-gauge needle and 25-gauge needle during lumbosacral transforaminal epidural steroid injections. TRIAL REGISTRATION: ClinicalTrials.gov NCT04350307. Registered 4/17/2020. (Retrospectively registered).

Lumbar Radiofrequency Ablation: Procedural Technique.

Lumbar radiofrequency ablation is indicated for the treatment of chronic axial low back pain that is mediated by facet arthropathy which has failed more conservative treatment options. This article details proper equipment and medications, patient positioning and setup, step-by-step instructions for multiplanar fluoroscopic visualization, cannula placement, and postoperative management. Pearls and pitfalls are also discussed. In addition, an instructional procedure video (Supplemental Digital Content 1, http://links.lww.com/CLINSPINE/A90) accompanies this paper.

Concomitant Use of Opioids and Benzodiazepines in the Outpatient Setting.

BACKGROUND: Benzodiazepines have been identified as a concurrent factor in opioid-related deaths. Although the dangers of concomitant administration of opioids and benzodiazepines are well documented, implementation of this knowledge into practice may be lagging behind. OBJECTIVE: To examine the concomitant use of opioids and benzodiazepines in the outpatient setting. DESIGN: Retrospective study. SETTING: Academic outpatient multispecialty practice. PARTICIPANTS: Over 2000 outpatient clinic visits from January 2018 to April 2018 among four physiatrists were analyzed. METHODS: All patients were reviewed in the Prescription Drug Monitoring Program (PDMP) website to identify whether they have filled either opioid or benzodiazepine prescription(s) in the last 12 months. MAIN OUTCOME MEASUREMENTS: Number of opioid and benzodiazepine prescriptions, discrepancies in reporting of medications, providers prescribing medications, and cigarette/alcohol use. RESULTS: A total of 353 patients were identified to have filled either opioid or benzodiazepine prescription(s) in last 12 months. 49.4% of patients prescribed opioids were found to be taking benzodiazepines concurrently. Reporting discrepancies were noted between the outpatient electronic medical record and PDMP in 17.2% of patients. Among patients taking both opioids and benzodiazepines, 38.9% had multiple providers prescribing these medications, 41.9% were over 65 years old, and 11.9% were daily cigarette/alcohol users. Patients taking both types of drugs (opioids and benzodiazepines) were significantly more likely to use different providers (38.9%) compared to patients taking one type of drug (9.8%, P < .001). The former group was also noted to fill significantly more prescriptions than the latter group (P < .001). CONCLUSION: The study results emphasize that clinicians may not be aware that some of their patients are concurrently taking opioids and benzodiazepines. These results highlight the importance of routinely checking the PDMP and using that information to make fully informed decisions to minimize risks in use of these controlled substances. LEVEL OF EVIDENCE: III.

Concomitant use of opioids and benzodiazepines in the outpatient setting: A retrospective study.

BACKGROUND: Benzodiazepines have been identified as a concurrent factor in opioid related deaths. Although the dangers of concomitant administration of opioids and benzodiazepines are well documented, implementation of this knowledge into practice may be lagging behind. OBJECTIVE: To examine the concomitant use of opioids and benzodiazepines in the outpatient setting. DESIGN: Retrospective study. SETTING: Academic outpatient multispecialty practice. PARTICIPANTS: Over 2000 outpatient clinic visits from January 2018 to April 2018 among 4 Physiatrists were analyzed. METHODS: All patients were reviewed in the Prescription Drug Monitoring Program (PDMP) website to identify if they have filled either opioid or benzodiazepine prescription(s) in the last 12 months. MAIN OUTCOME MEASUREMENTS: Number of opioid and benzodiazepine prescriptions, discrepancies in reporting of medications, providers prescribing medications, and cigarette/alcohol use. RESULTS: 353 patients were identified to have filled either opioid or benzodiazepine prescription(s) in last 12 months. 49.4% of patients prescribed opioids were found to be on benzodiazepines concurrently. Reporting discrepancies were noted between the outpatient electronic medical record and PDMP in 17.2% of patients. Among patients on both opioids and benzodiazepines, 38.9% had multiple providers prescribing these medications, 41.9% were over 65 years old, and 11.9% were daily cigarette/alcohol users. Patients on both types of drugs (opioids and benzodiazepines) were significantly more likely to use different providers (38.9%) compared to patients on one type of drug (9.8%, p<.001). The former group was also noted to fill significantly more prescriptions than the latter group (p<.001). CONCLUSION: The study results emphasize clinicians may not be aware that some of their patients are concurrently taking both opioids and benzodiazepines, hence highlights the importance of routinely checking the PDMP and utilizing that information to make fully informed decisions regarding the safest possible way to prescribe these controlled substances. LEVEL OF EVIDENCE: III.

Improving Fluoroscopic Visualization for Lower Cervical Medial Branch Blocks with a Modified Swimmer's View: A Technical Report.

BACKGROUND: Neural blockade of the cervical medial branches is a validated procedure in the diagnosis and treatment of cervical zygapophyseal joint pain. Fluoroscopic visualization of the lower cervical medial branch target zones (CMBTZs) in lateral view is sometimes challenging or not possible due to the patient's shoulders obscuring the target. Large shoulders and short necks often exacerbate the problem. Clear visualization is critical to accuracy and safety. OBJECTIVE: We aim to describe a method for optimal fluoroscopic visualization of the lower CMBTZs using a modified swimmer's view. STUDY DESIGN: A technical report. SETTING: A private practice. METHODS: Discussion with accompanying fluoroscopic images of the cervical spine, focusing on the lateral aspects of the lower cervical articular pillars in both the traditional lateral view and modified swimmer's view. Four authors served as volunteers for undergoing fluoroscopic x-rays in both views. Visualization of each lower CMBTZ was attempted and stored. The most caudal, clearly visualized levels were compared in both views for each participant. RESULTS: Visualization of the lower CMBTZs can be successfully obtained with the modified swimmer's view and in select patients is superior to a lateral view. LIMITATIONS: A limitation to this study is the design as a technical report. A future prospective study is warranted. CONCLUSIONS: Modified swimmer's view can serve as a primary method of visualizing the lower CMBTZs or an alternate view when a lateral view is unable to clearly demonstrate target landmarks. This can improve the ease, accuracy, and safety of performing diagnostic cervical medial branch blocks (CMBBs). KEY WORDS: Swimmer's view, cervical medial branch block, facet joint, fluoroscopy.

Fluoroscopically Guided Lumbar Transforaminal Epidural Steroid Injection: Procedural Technique.

Fluoroscopically guided lumbar transforaminal epidural steroid injections are indicated for the treatment of lumbar radicular pain that has failed more conservative options. This article details proper equipment and medications, patient positioning and set-up, step-by-step instructions for multiplanar fluoroscopic visualization, needle advancement and medication instillation, and postoperative management. Pearls and pitfalls are also discussed. In addition, an instructional procedure video accompanies this paper.

Incidence of neuropathic pain after cooled radiofrequency ablation of sacral lateral branch nerves.

OBJECTIVE: To determine the incidence of neuropathic pain after cooled radiofrequency ablation (RFA) of the sacral lateral branches for the treatment of chronic posterior sacroiliac joint complex pain. DESIGN: Retrospective chart review of all patients with chronic posterior sacroiliac joint complex pain who underwent cooled RFA of the sacral lateral branches in our practice between July 2011 and February 2014. SETTING: Single academic pain practice at a tertiary care medical center. SUBJECTS: Thirty-six patients with chronic posterior sacroiliac joint complex pain. METHODS: All charts were reviewed to determine the procedure date, unilateral or bilateral, number of levels treated, and number of individual lesions. Side effects were assessed for their presence or absence, character, intensity, duration, and whether treatment was initiated or symptoms resolved spontaneously. RESULTS: Forty-eight separate procedures were performed, with a total of 193 levels and 430 lesions. Three patients had transient postprocedure neuropathic pain yielding a 0.7% (95% confidence interval [CI]± 0.4%) rate of this complication per lesion. This proportion increases to 6.2% (95% CI ± 3.5%) per procedure and to 9.4% (95% CI ± 5.2%) per patient. CONCLUSION: The incidence of postprocedural neuropathic pain after cooled RFA for posterior sacroiliac joint complex denervation is low and in a similar range to that in the lumbar spine. We consider this procedure safe to be utilized by pain medicine practitioners.

Current and future interventions for glenohumeral subluxation in hemiplegia secondary to stroke.

Poststroke shoulder pain is a common issue and can be caused by glenohumeral subluxation. This entity hinders function and quality of life and is caused by changes in tone and loss of fi ne control of the shoulder joints' supporting structures after a stroke. Current treatments are limited in number and effectiveness and have significant problems and limitations to their use. Furthermore, prior to percutaneous implantable neuromuscular electrical stimulation, there was no evidence for any treatment to provide relief for chronic hemiplegic shoulder pain from glenohumeral subluxation. This clinical review provides a comprehensive review of the anatomy, pathogenesis, clinical features, management, and clinical efficacy of current treatment modalities.