THE ASSOCIATION BETWEEN CORTICOSTEROID DOSE AND PAIN REDUCTION FOLLOWING SACROILIAC JOINT INJECTIONS.

OBJECTIVE: Sacroiliac joint (SIJ) mediated back pain has proven therapeutic benefit from fluoroscopically guided SIJ corticosteroid injections. We examined corticosteroid dose and pain relief following fluoroscopically guided SIJ injections to better understand their relationship. DESIGN: Retrospective observational cohort analysis of electronic health record data on 661 patients who received unilateral fluoroscopically guided SIJ intraarticular corticosteroid injection with 40 mg versus 80 mg of methylprednisolone from 2012 and 2019. Patients were injected by fellowship trained proceduralists after diagnosis by board certified physiatrists in an academic physiatry practice. Absolute change in pain scores (post-procedure and first follow up) was modeled using linear regression of methylprednisolone dosage (40 mg vs. 80 mg) controlling for age, sex, BMI, baseline pain scores, and follow-up time. RESULTS: Linear regression indicated that dosage of methylprednisolone, age and BMI were not statistically significantly associated with change in pain scores. Sex approached significance (p = 0.0501) indicating that females may have a lower degree of pain resolution than males. CONCLUSIONS: Practitioners should consider corticosteroid dose when performing these beneficial procedures. This could reduce cost and potential side effects associated with larger doses, while still providing therapeutic benefit. This pilot study can guide future research and dosing guidelines for fluoroscopic spine injections.

Atypical Cause for Back Pain and Sciatica in a 35-Yr-Old Woman With Fibromyalgia.

ABSTRACT: Spinal and extrapelvic lesions causing sciatic symptoms are well recognized in clinical research and practice. 1-5 We present a 35-yr-old woman with a history of axial back pain and fibromyalgia who presented with episodes of radicular type pain down her legs and associated bilateral tingling in her feet. Medicinal and therapeutic interventions for traditional sciatica etiologies failed to provide relief. Lumbar magnetic resonance imaging showed mild multilevel degenerative changes and partially visualized fibroids, but no other significant spinal pathology was appreciated. Subsequent pelvic magnetic resonance imaging revealed an enlarged retroverted uterus with multiple fibroid lesions. The patient elected for laparoscopic myomectomy, which improved her likelihood of fertility while drastically alleviating her axial spine and lower extremity symptomology. This case reinforces the importance of keeping a broad differential that includes intrapelvic etiologies when traditional workup and treatment for sciatic neuropathy fails. To our knowledge, this is the first reported case of sciatic neuropathy secondary to uterine fibroids treated with the intent of both fertility improvement and pain relief.

Measuring case severity: a novel tool for benchmarking and clinical documentation improvement.

BACKGROUND: Severity of illness (SOI) is an All Patients Refined Diagnosis Related Groups (APR DRG) modifier based on comorbidity capture. Tracking SOI helps hospitals improve performance and resource distribution. Furthermore, benchmarking SOI plays a key role in Quality Improvement (QI) efforts such as Clinical Documentation Improvement (CDI) programs. The current SOI system highly relies on the 3 M APR DRG grouper that is updated annually, making it difficult to track severity longitudinally and benchmark against hospitals with different patient populations. Here, we describe an alternative SOI scoring system that is grouper-independent and that can be tracked longitudinally. METHODS: Admission data for 2019-2020 U.S. News and World Report Honor Roll facilities were downloaded from the Vizient Clinical Database and split into training and testing datasets. Elixhauser comorbidities, body systems developed from the Healthcare Cost and Utilization Project (HCUP), and ICD-10-CM complication and comorbidity (CC/MCC) indicators were selected as the predictors for orthogonal polynomial regression models to predict patients' admission and discharge SOI. Receiver operating characteristic (ROC) and Precision-Recall (PR) analysis, and prediction accuracy were used to evaluate model performance. RESULTS: In the training dataset, the full model including both Elixhauser comorbidities and body system CC/MCC indicators had the highest ROC AUC, PR AUC and predication accuracy for both admission (ROC AUC: 92.9%; PR AUC: 91.0%; prediction accuracy: 85.4%) and discharge SOI (ROC AUC: 93.6%; PR AUC: 92.8%; prediction accuracy: 86.2%). The model including only body system CC/MCC indicators had similar performance for admission (ROC AUC: 92.4%; PR AUC: 90.4%; prediction accuracy: 84.8%) and discharge SOI (ROC AUC: 93.1%; PR AUC: 92.2%; prediction accuracy: 85.6%) as the full model. The model including only Elixhauser comorbidities exhibited the lowest performance. Similarly, in the validation dataset, the prediction accuracy was 86.2% for the full model, 85.6% for the body system model, and 79.3% for the comorbidity model. With fewer variables and less model complexity, the body system model was more efficient and was determined to be the optimal model. The probabilities generated from this model, named J_Score and J_Score_POA, successfully measured SOI and had practical applications in assessment of CDI performance. CONCLUSIONS: The J_Scores generated from the body system model have significant value in evaluating admission and discharge severity of illness. We believe that this new scoring system will provide a useful tool for healthcare institutions to benchmark patients' illness severity and augment Quality Improvement (QI) efforts.

The association between medication use and cognitive performance in people with SCI.

PURPOSE/OBJECTIVE: Polypharmacy is common in people with spinal cord injury (SCI). Given the high rates of medication use, and the complicated side effect profile of many of the medications that are regularly prescribed in people with SCI, we were interested in the association between the use of different classes of medications and cognitive function in these individuals. Research Method/Design: One-hundred and 73 people with SCI participated in an observational study. Self-reported medications were provided by participants. Participants also completed several cognitive tests designed to capture multiple aspects of cognition (processing speed, attention, working memory, learning, free-recall memory, delayed free recall memory, executive function), as well as a self-report measure that captures participant perceptions of cognitive function. A series of multivariable linear regressions were used to test for associations between medications and the seven measures of cognition. RESULTS: In general, there was not a robust relationship between medication use and cognitive function; the sole exception was an association between opioid use and subjective cognitive function. There was some preliminary support for an association between medication use, especially benzodiazepine and opioid analgesic use, and poorer cognitive performance. Specifically: Opioid analgesic use was associated with slowed processing speed, worse attention, poorer working memory, poorer executive function and more subjective cognitive complaints; benzodiazepine use was associated with slower processing speed, poorer working memory, and worse executive function; anticonvulsant use was related to worse delayed free recall memory; and the number of medication categories a person with SCI was taking was related to slower processing speed, and worse subjective cognitive function. Antidepressant, cannabis, skeletal muscle relaxant, sedative and stimulant use were not significantly related to cognitive performance, nor to subjective reports of cognitive function. CONCLUSIONS/IMPLICATIONS: Findings did not support a strong relationship between medication use and cognitive function in people with SCI. There is some preliminary support for an association between benzodiazepine use and cognitive performance, but this needs to be confirmed in future research. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Safety of fluoroscopically guided pain procedures in patients receiving cytotoxic chemotherapy: a retrospective analysis.

PURPOSE: To examine the incidence of bleeding and infectious adverse events (AEs) in patients undergoing interventional, fluoroscopic-guided axial spine procedures to modulate pain. METHODS: Retrospective data of patients undergoing fluoroscopically guided axial spine injections at a single tertiary care medical center Cancer Rehabilitation program in the USA were reviewed. AEs, type of chemotherapy, type of tumor, age, platelet and absolute neutrophil counts (ANC) prior to the procedure, and relevant past medical history were collected. Descriptive statistical analyses were performed. RESULTS: Sixty-three separately identifiable procedures across 28 patients met inclusion criteria. Zero AEs were recorded. Platelet and ANC were generally above the recommended safety threshold, but granulocyte colony stimulating factor was administered prior to four procedures to boost ANC levels. Multiple myeloma was the most common cancer diagnosis (64.3%). Various solid tumors made up the remaining cancer diagnoses. Epidural steroid injections (n=23) and medial branch blocks (n=23) were the most common procedures performed and lumbar (n=35) was the most common location of procedures. Three patients died within 30 days of the procedures but their deaths were not directly attributable to the injections. CONCLUSION: This provides preliminary data to support the safety of injections in patients receiving cytotoxic chemotherapy. Larger, multicenter studies are required before firm conclusions can be drawn.

Initial validation of the electronic form of the Michigan Body Map.

BACKGROUND: The Michigan Body Map (MBM) was developed to assess pain location in a reliable and valid manner; however, electronic formats have not been validated. This study had two aims: (1) initial validation of the electronic form of the MBM (eMBM) and (2) preliminary test of assessing pain severity within body zones. METHODS: For the first aim, 68 participants with chronic pain completed paper and electronic forms of the MBM, then underwent scripted interviews to assess preferences among body maps and verbal confirmation of pain locations. For the second aim, a subset of the participants (n=40) completed the Brief Pain Inventory (BPI) pain severity subscale, as well as the eMBM again and endorsed pain severity using additional screens showing body zones that contained areas in which pain was endorsed. RESULTS: There were few discrepancies between MBM, eMBM and verbal report (1.9% and 1.6%, respectively), and no difference between forms in perceived ability to indicate areas of pain or ease of completion. Patients accurately indicated their bodily pain on both maps, with 84% and 87% reporting one or no errors on MBM and eMBM, respectively. Participants also reported no preference for which version best-depicted areas of pain or best distinguished left from right. Lastly, the most preferred measure was eMBM with pain severity zones, followed by eMBM without zones, followed by the BPI pain severity subscale. CONCLUSIONS: These data support the validity of the eMBM for patients with chronic pain. Further, an expanded form of the eMBM that assesses pain severity was preferred by most participants.

Improved Comorbidity Capture Using a Standardized 1-Step Quality Improvement Documentation Tool.

Objective To assess the impact of implementation of a "1-step" documentation query system on comorbidity capture and quality outcomes within the Department of Otolaryngology-Head and Neck Surgery. Methods Implementation of the 1-step documentation query system was instituted for all otolaryngology-head and neck surgery faculty at a single institution. Individual query responses and impact metrics were analyzed. Departmental case-mix index (CMI), risk of mortality (ROM), and severity of illness (SOI) were collated over a 14-month implementation period and compared to a 12-month preimplementation period. Results A total of 226 documentation queries occurred during the program pilot period, with an 86.7% response rate. Of queries with a response, 91.0% resulted in a significant impact for the hospitalization diagnoses-related group, ROM, or SOI. Departmental CMI increased from 2.73 to 2.91 over the implementation period, and observed/expected mortality ratio decreased from 0.50 to 0.42 pre- to postimplementation. Discussion With increasing emphasis on quality metrics outcomes within the United States health care system, there is a need for institutions to accurately capture the complexity and acuity of the patients they care for. There was a positive change in quality outcomes metrics, including ROM, SOI, and CMI over the first year of deployment of the 1-step documentation query process. Implications for Practice Clinical severity metrics are becoming increasingly important to otolaryngologists, as insurers move to severity-adjusted profiles. The 1-step documentation query process provides a reproducible and effective way for clinical documentation specialists and physicians to collaborate on improving departmental clinical severity metrics.

Preliminary validation of the Michigan Body Map.

We developed the Michigan Body Map (MBM) as a self-report measure to assess body areas where chronic pain is experienced and to specifically quantify the degree of widespread body pain when assessing for centralized pain features (eg, fibromyalgia-like presentation). A total of 402 patients completed the measure in 5 distinct studies to support the validation of the original and a revised version of the MBM. Administration is rapid 39 to 44 seconds, and errors for the original MBM were detected in only 7.2% of the possible body areas. Most errors underestimated the number of painful areas or represented confusion in determining the right vs left side. The MBM was preferred (P = 0.013) and felt to better depict pain location (P = 0.001) when compared with the Widespread Pain Index checklist of the 2011 Fibromyalgia Survey Criteria, but participants did not express any preference between the MBM and Brief Pain Inventory body map. Based on the data from the first 3 studies, a revised version of the MBM was created including a front and back body image and improved guidance on right-sidedness vs left. The revised MBM was preferred when compared with the original and was more accurate in depicting painful body areas (P = 0.004). Furthermore, the revised MBM showed convergent and discriminant validity with other self-report measures of pain, mood, and function. In conclusion, the MBM demonstrated utility, reliability, and construct validity. This new measure can be used to accurately assess the distribution of pain or widespread bodily pain as an element of the fibromyalgia survey score.

The Effects of Local Anesthesia Administration on Pain Experience During Interventional Spine Procedures: A Prospective Controlled Trial.

OBJECTIVE: It has been postulated that local anesthetic administration may be the most painful part of interventional spine procedures. Despite this, there is a lack of evidence supporting the commonly used traditional technique of anesthetic delivery as part of these procedures. This study tested three hypotheses: 1) alternative method of local anesthesia injection is superior to the traditional method; 2) using the traditional method of injection is not superior to using no local anesthetic; and 3) treatment needle size, anesthetic injection technique, and sedation are associated with pain experienced during procedures. DESIGN: Prospective, multicenter clinical trial of 127 participants who underwent elective bilateral symmetric interventional spine procedures in outpatient spine clinics. METHODS: Primary outcomes were pain scores during and after procedures to examine the influence of anesthetic injection method and treatment needle gauge on pain experience using linear mixed model regression analysis. A post-hoc comparison of estimated marginal mean pain scores was completed on both anesthetic injection method and treatment needle gauge. CONCLUSIONS: The alternative method was superior (P < 0.05) to the traditional method on post procedural pain scores. Injecting local anesthetic with the traditional or alternative method was not superior to using no local anesthetic. Treatment needle size, pain at one inch of treatment needle insertion, and baseline pain were all significantly (P < 0.05) associated with overall procedural pain. Further studies are needed optimize and justify local anesthetic injections for these procedures.

Using Lean principles to manage throughput on an inpatient rehabilitation unit.

Performance improvement is a mainstay of operations management and maintenance of certification. In this study at a University Hospital inpatient rehabilitation unit, Lean management techniques were used to manage throughput of patients into and out of the inpatient rehabilitation unit. At the start of this process, the average admission time to the rehabilitation unit was 5:00 p.m., with a median time of 3:30 p.m., and no patients received therapy on the day of admission. Within 8 mos, the mean admission time was 1:22 p.m., 50% of the patients were on the rehabilitation unit by 1:00 p.m., and more than 70% of all patients received therapy on the day of admission. Negative variance from this performance was evaluated, the identification of inefficient discharges holding up admissions as a problem was identified, and a Lean workshop was initiated. Once this problem was tackled, the prime objective of 70% of patients receiving therapy on the date of admission was consistently met. Lean management tools are effective in improving throughput on an inpatient rehabilitation unit.