Neuropsychiatric Side Effects After Lumbosacral Epidural Steroid Injections: A Prospective Cohort Study.

BACKGROUND: The central nervous system contains steroid receptors, particularly in the hypothalamic and limbic systems. These systems are responsible for driving certain emotions in humans, especially stress, anxiety, motivation, energy levels, and mood. Thus, corticosteroids may precipitate patients to experience these emotions. Most existing studies report neuropsychiatric side effects after oral or intravenous corticosteroids rather than epidural. OBJECTIVES: This study examines the neuropsychiatric side effects after epidural steroid injections (ESIs), with a focus on whether certain factors in patients' histories further exacerbate symptomatology. STUDY DESIGN: Prospective observational cohort study. SETTING: Fluoroscopy suite at an urban academic teaching hospital. METHODS: Patients were called 24 hours and one week after their ESIs and asked if they experienced certain neuropsychiatric symptoms more than usual compared to baseline. PATIENTS: Seventy-four patients undergoing a lumbosacral ESI (interlaminar (ILESI), caudal or transforaminal (TFESI)) were invited to take part in the study the day of his or her procedure. INTERVENTION/MEASUREMENT: Assessed whether psychiatric history, gender, race, type of ESI, or the number of levels injected affected frequency and duration of neuropsychiatric symptoms at one day and one week after an ESI. RESULTS: Significantly (P < 0.05) more patients with a psychiatric history experienced restlessness and irritability at day one than those without a psychiatric history. At week one, male gender (IRR 2.29, 95% CI 1.37, 3.83, P = 0.002), ILESI (IRR 7.75, 95% CI 1.03, 58.6, P = 0.047), and 2-level injections (IRR 2.14, 95% CI 1.13, 4.06, P = 0.019) were significantly associated to more total symptoms. LIMITATIONS: Single center study, reliance on subjective responses from patients, lack of follow-up after one week post-ESI. CONCLUSION(S): This study demonstrates that neuropsychiatric symptoms are rare overall after an ESI, though certain factors may influence patients experiencing these symptoms. Restlessness and irritability were more likely to occur one day after an ESI in those with a psychiatric history. Those who had a 2-level injection were more likely to keep experiencing most symptoms by week one, suggesting a possible correlation between corticosteroid dose and neuropsychiatric symptoms.

Prescription Trends of Opioid and Nonopioid Controlled Prescription Adjunctive Analgesics Before and After Cervical Spinal Surgery: A Retrospective Cohort Study.

OBJECTIVE: Cervical spine surgery may be needed in those with refractory pain or neurologic deficits to improve outcomes in patients with cervical spine disease. However, consensus varies in the literature on the effect of surgery on opioid use. The objectives of this study were to analyze prescription rates of multiple controlled substances before and after cervical spine surgery and distinguish factors that may have contributed to opioid use after surgery. DESIGN: This is a retrospective cohort study analyzing prescription trends of various controlled substances in 632 patients who underwent cervical spine surgery from 2019 to 2021. RESULTS: Opioids have the largest rise in prescriptions at 3- and 6-mo time points after cervical spine surgery. A significant association ( P < 0.001) was found between opioid use 1 yr before and 1 yr after cervical spine surgery. Exposure to opioids before surgery (odds ratio = 2.77, 95% confidence interval = 1.43-5.51, P = 0.003) and higher morphine milligram equivalent dose (odds ratio = 1.02, 95% confidence interval =1.01-1.04, P = 0.012) were found to be associated with opioid use after surgery. Significantly more females were prescribed controlled substances ( P = 0002). CONCLUSIONS: Higher morphine milligram equivalent dose and opioid exposure before surgery are important factors in predicting postsurgical opioid use.

Prescription Trends in Complex Regional Pain Syndrome: A Retrospective Case-Control Study.

OBJECTIVE: The objective of this study was to evaluate discrepancies in prescription trends for analgesic medications in complex regional pain syndrome (CRPS) patients based on recommendations in the literature. DESIGN: We conducted a retrospective case-control study. SUBJECTS: A total of 2510 CRPS patients and 2510 demographic-matched controls participated in this study. METHODS: The SlicerDicer feature in Epic was used to find patients diagnosed with CRPS I or II between January 2010 and November 2022. An equal number of age-, gender-, and race-matched controls without a CRPS diagnosis were retracted from Epic. General and CRPS-associated prescription frequencies for the following classes were retrieved for both cases and controls: benzodiazepines, bisphosphonates, calcitonin, capsaicin, neuropathic pain medications, NSAIDs, opioids, and steroids. RESULTS: A total of 740 (29%) CRPS patients and 425 (17%) controls were prescribed benzodiazepines (95% CI 0.1-0.15), 154 (6.1%) CRPS patients and 52 (2.1%) controls were prescribed capsaicin (95% CI 0.03-0.05), 1837 (73%) CRPS patients and 927 (37%) controls were prescribed neuropathic pain medications (95% CI 0.05-0.34), 1769 (70%) CRPS patients and 1217 (48%) controls were prescribed opioids (95% CI 0.19-0.25), 1095 (44%) CRPS patients and 1217 (48%) controls were prescribed steroids (95% CI 0.08-0.14), and 1638 (65%) CRPS patients and 1765 (70%) controls were prescribed NSAIDs (95% CI -0.08-0.02), p < 0.001 for all classes. With CRPS-associated prescriptions, (95% CI 0.05-0.16, p < 0.001) more CRPS patients were prescribed opioids (N = 398, 59%) than controls (N = 327, 49%). CONCLUSIONS: CRPS is difficult to treat with significant variance in suggested treatment modalities. Based on the results of our study, there is a divergence between some published recommendations and actual practice.

Spinal cord infarction attributed to SARS-CoV-2, with post-acute sequelae of COVID-19: A case report.

BACKGROUND: While stroke and lower extremity venous thromboemboli have been commonly reported following acute infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), spinal cord infarction or ischemia has been extremely rare. Findings of long coronavirus disease (COVID) in this select population have not been studied. CASE SUMMARY: We present the case of a 70-year-old female with sudden onset of trunk and lower extremity sensorimotor loss due to spinal cord infarction, attributed to acute infection with SARS-CoV-2. Diagnostic work up confirmed a T3 complete (ASIA impairment Scale A) paraplegia resulting from a thrombotic infarct. Her reported myalgias, neuropathic pain, spasticity, bladder spasms, and urinary tract infections exceeded the frequency and severity of many spinal cord injury (SCI) individuals of similar age and degree of neurologic impairment. In her first year after contracting COVID-19, she underwent 2 separate inpatient rehabilitation courses, but also required acute hospitalization 6 additional times for subsequent infections or uncontrolled pain. Yet other complications of complete non-traumatic SCI (NTSCI), including neurogenic bowel and temperature hypersensitivity, were mild, and pressure injuries were absent. She has now transitioned from the acute to chronic phase of spinal cord injury care, with subsequent development of post-acute sequelae of SARS-CoV-2 infection (PASC). CONCLUSION: This individual experienced significant challenges with the combined effects of acute T3 NTSCI and acute COVID-19, with subsequent progression to PASC.

Effect of modifiable risk factors in Parkinson's disease: A case-control study looking at common dietary factors, toxicants, and anti-inflammatory medications.

OBJECTIVE: To investigate how common modifiable exposures, including dietary factors, select toxicants, and anti-inflammatory medications, may affect Parkinson's disease. METHODS: Using surveys, a case-control study was conducted at a medical center, comparing Parkinson's disease patients (N = 149) and healthy controls (N = 105). Subjects reported exposure to red meats, vegetables, alcohol, tobacco, anti-inflammatory medications, and pesticides. The relationship between exposures and Parkinson's disease diagnosis was analyzed by logistic regression to generate odds ratio and 95% confidence interval. RESULTS: Consuming red meat "sometimes" or "always" was positively associated with Parkinson's disease as compared to eating red meats "rarely" or "never"; (odds ratio = 2.15, 95% confidence interval = 1.06, 4.39; p = 0.03) and (odds ratio = 4.47, 95% confidence interval = 1.67, 11.94; p = 0.003), respectively. Exposure to pesticides showed a positive association with Parkinson's disease (odds ratio = 2.84, 95% confidence interval = 1.34, 6.00; p = 0.007). "Always" use of aspirin was inversely associated with Parkinson's disease (odds ratio = 0.32, 95% confidence interval = 0.14, 0.70; p = 0.004). "Ever" having used anti-histamines was inversely associated with Parkinson's disease (odds ratio = 0.37, 95% confidence interval = 0.17, 0.81; p = 0.01). DISCUSSION: Our study suggests that there are modifiable external factors that are associated with Parkinson's disease. The present study can thus assist clinicians, policy makers, and people living with Parkinson's disease in improving the experience and management of Parkinson's disease.

Taxonomy of the Lateral Strain Patterns at the Sphenobasilar Synchondrosis for Osteopathic Cranial Manipulative Medicine.

Lateral strain is a type of nonphysiologic cranial dysfunction that occurs at the sphenobasilar synchondrosis. In this dysfunction, the sphenoid and occiput rotate in the same directions along 2 vertical axes. There is currently no consensus on the nomenclature for this cranial dysfunction. In this article, the authors provide a standard nomenclature for lateral strains using the historical writings of pioneers in osteopathic medicine, including William Gardner Sutherland, DO, Anne L. Wales, DO, and Harold Magoun, DO. The authors establish the following consensus: (1) Lateral strains are named for the side to which the basisphenoid shifts; (2) The more prominent greater wing of the sphenoid is on the same side to which the basisphenoid shifts; (3) In vault and fronto-occipital holds, the holds form a parallelogram shape, with the index fingers pointing to the same side as the more prominent greater wing; and (4) The hand that is on the side of the prominent greater wing will shift anteriorly while the hand on the opposite side will shift posteriorly.

Gait Study of Parkinson's Disease Subjects Using Haptic Cues with A Motorized Walker.

Gait abnormalities are one of the distinguishing symptoms of patients with Parkinson's disease (PD) that contribute to fall risk. Our study compares the gait parameters of people with PD when they walk through a predefined course under different haptic speed cue conditions (1) without assistance, (2) pushing a conventional rolling walker, and (3) holding onto a self-navigating motorized walker under different speed cues. Six people with PD were recruited at the New York Institute of Technology College of Osteopathic Medicine to participate in this study. Spatial posture and gait data of the test subjects were collected via a VICON motion capture system. We developed a framework to process and extract gait features and applied statistical analysis on these features to examine the significance of the findings. The results showed that the motorized walker providing a robust haptic cue significantly improved gait symmetry of PD subjects. Specifically, the asymmetry index of the gait cycle time was reduced from 6.7% when walking without assistance to 0.56% and below when using a walker. Furthermore, the double support time of a gait cycle was reduced by 4.88% compared to walking without assistance.