What does the patient with back pain want? A comparison of patient preferences and physician assumptions.

BACKGROUD CONTEXT: Low back pain can be difficult to diagnose, leaving patients frustrated and confused after medical visits. PURPOSE: To evaluate the importance of reasons for seeking care in patients with back pain, and to compare this to physicians' assumptions about these patients' reasons. STUDY DESIGN/SETTING: Prospective survey study carried out at two academic spine centers. PATIENT SAMPLE: A sum of 419 patients with back pain upon initial presentation to a spine clinic, and 198 physicians; all volunteered to complete a survey. OUTCOME MEASURES: Variance in mean values between patient and physician responders with significance determined by non-overlapping 95% confidence intervals. METHODS: Patients were asked to "rate each of the following with regard to their importance to you" (answering between 0 "not important" to 4 "extremely important"): improvement in level of pain, improvement in ability to perform daily tasks, explanation of what is causing your problem, thorough physical examination, diagnostic testing, medication, physical therapy, surgery. Physicians were asked to rate each of these "with regard to their importance to your patients." RESULTS: Patients indicated the following items were the most important (mean values): explanation of what is causing your problem (3.27), improvement in level of pain (3.48) and improvement in ability to perform daily tasks (3.31). Patients attributed the least importance and lowest scores to: surgery (1.07) and medication (1.89). Comparing the mean values to each item by patient and physician responders revealed statistically significant differences in certain items. Specifically, physicians underestimated the importance of an explanation of what is causing the problem (2.78±0.119 vs. 3.28±0.098, 95% CI) and overvalued diagnostic tests (2.64±0.120 vs. 2.30±0.147, 95% CI), medications (2.38±0.118 vs. 1.89± 0.143, 95% CI) and surgery (1.60±0.126 vs. 1.07±0.140, 95% CI). CONCLUSION: Patients did not place as much importance on diagnostic tests, medications and surgery as the physicians assumed. Physicians understand that back pain patients want improvement in both pain and function, but they underestimate the importance of an explanation for the pain.

Extensor digitorum brevis bulk and associations with fibular motor nerve conduction amplitude.

INTRODUCTION: Prior work demonstrates that fibular compound motor action potential (CMAP) amplitude <4.0 mV predicts impairment of ankle proprioceptive precision and increased fall risk. Extensor digitorum brevis (EDB) inspection may present a simple clinical surrogate for CMAP amplitude. OBJECTIVE: (1) To estimate the inter-rater reliability of assessment of EDB bulk. (2) To determine whether inspection of EDB bulk is associated with fibular CMAP amplitude. DESIGN: Prospective inter-rater reliability study. SETTING: Academic center outpatient Physical Medicine & Rehabilitation electromyography (EMG) clinics. PARTICIPANTS: Fifty-two adult participants (102 feet). MAIN OUTCOME MEASURES: (1) Inter-rater reliability of assessment of EDB bulk. (2) Mean fibular CMAP amplitude. (3) A binary measure of fibular CMAP amplitude at/above or below a 4.0 mV threshold. RESULTS: Inter-rater reliability of EDB bulk grading was moderate (kappa: 0.65 [95% confidence interval (CI) 0.48-0.82]). The mean CMAP value was 5.9 ± 2.2 mV when bulk was normal, 3.4 ± 2.1 mV when diminished, and 0.6 ± 0.9 mV when atrophied. A multivariable analysis demonstrated that EDB bulk, distal symmetric polyneuropathy (DSP), and lumbar radiculopathy were all associated with CMAP amplitude. The sensitivity and specificity of grading muscle bulk as normal versus abnormal in detecting CMAP amplitude above or below 4.0 mV were 0.86 (95% CI 0.78-0.94) and 0.71 (95% CI 0.54-0.88), respectively. An atrophied EDB was a highly specific indicator that CMAP amplitude was abnormal (<4.0 mV) in 100% of cases (8/8). CONCLUSIONS: EDB bulk was associated with fibular CMAP amplitude. Atrophy was a highly specific indicator for CMAP amplitude below 4.0 mV. Evaluation of EDB bulk may represent a quick and easy clinical surrogate marker for CMAP amplitude and distal neuromuscular impairment.

Prospective, randomized, multicenter study of intraosseous basivertebral nerve ablation for the treatment of chronic low back pain: 12-month results.

INTRODUCTION: Vertebral endplates, innervated by the basivertebral nerve (BVN), are a source of chronic low back pain correlated with Modic changes. A randomized trial comparing BVN ablation to standard care (SC) recently reported results of an interim analysis. Here, we report the results of the full randomized trial, including the 3-month and 6-month between-arm comparisons, 12-month treatment arm results, and 6-month outcomes of BVN ablation in the former SC arm. METHODS: Prospective, open label, 1:1 randomized controlled trial of BVN ablation versus SC in 23 US sites with follow-up at 6 weeks, 3, 6, 9, and 12 months. SC patients were re-baselined and followed up for 6 months post BVN ablation. The primary endpoint was the between-arm comparison of mean Oswestry Disability Index (ODI) change from baseline. Secondary endpoints were Visual Analog Scale (VAS), Short Form (SF-36), EuroQual Group 5 Dimension 5-Level Quality of Life (EQ-5D-5L), responder rates, and rates of continued opioid use. RESULTS: 140 were randomized. Results from BVN ablation (n=66) were superior to SC (n=74) at 3 months for the primary endpoint (mean ODI reduction, difference between arms of -20.3 (CI -25.9 to -14.7 points; p<0.001)), VAS pain improvement (difference of -2.5 cm between arms (CI -3.37 to -1.64, p<0.001)) and quality of life outcomes. At 12 months, basivertebral ablation demonstrated a 25.7±18.5 point reduction in mean ODI (p<0.001), and a 3.8±2.7 cm VAS reduction (p<0.001) from baseline, with 64% demonstrating ≥50% reduction and 29% pain free. Similarly, the former SC patients who elected BVN ablation (92%) demonstrated a 25.9±15.5 point mean ODI reduction (p<0.001) from baseline. The proportion of opioid use did not change in either group (p=0.56). DISCUSSION/CONCLUSION: BVN ablation demonstrates significant improvements in pain and function over SC, with treatment results sustained through 12 months in patients with chronic low back pain of vertebrogenic origin.

The Value of Electrodiagnostic Studies in Predicting Treatment Outcomes for Patients with Spine Pathologies.

The utility of electrodiagnostic testing for spine pathologies varies based on the underlying suspected pathology. This article reviews the data on electrodiagnostic testing for common spine pathologies, with a specific focus on the prognostic data with regard to treatment outcomes. This information is placed into context of diagnostic confidence, which is derived from the combination of disease prevalence and the sensitivity and specificity of a test.

Cervical Epidural Steroid Injection: Techniques and Evidence.

Cervical epidural steroid injections are a common treatment of cervical radicular pain. Important safety considerations include attention to the possibility of spinal cord infarction and spinal epidural hematoma. When appropriate, radiographic, technical, and pharmacologic principals are used, these procedures are relatively safe. Cervical epidural steroid injections are effective for the short-term treatment of radicular pain. More rigorously designed clinical outcomes studies of both cervical interlaminar and transforaminal epidural steroid injections are needed.

Downregulation of Connexin 43 promotes vascular cell loss and excess permeability associated with the development of vascular lesions in the diabetic retina.

PURPOSE: To determine whether downregulation of Connexin 43 (Cx43) expression promotes development of acellular capillaries (ACs), pericyte loss (PL), excess permeability, and retinal thickening in rat retinas. METHODS: Control rats, diabetic rats, and rats intravitreally injected with Cx43 siRNA or scrambled siRNA were used in this study to determine if acute downregulation of Cx43 expression contributes to retinal vascular cell death and excess permeability. Western blot (WB) analysis and Cx43 immunostaining were performed to assess Cx43 protein levels and distribution in the retinal vessels. Concurrently, retinal networks were subjected to terminal deoxynucleotidyl transferase-mediated uridine 5'-triphosphate-biotin nick end labeling (TUNEL) assay and counter-stained to assess the number of apoptotic cells, ACs, and PL. Assessment of fluorescein isothiocyanate-dextran (FITC-dex) extravasation from retinal capillaries and optical coherence tomography (OCT) were performed to determine retinal vascular permeability and retinal thickness, respectively. RESULTS: WB analysis indicated a significant decrease in the Cx43 protein level in the retinas of the diabetic rats and those intravitreally injected with Cx43 siRNA compared to the retinas of the control rats. Likewise, the retinal vascular cells of the diabetic rats and the Cx43 siRNA-treated rats showed a significant decrease in Cx43 immunostaining. Importantly, the number of apoptotic cells, ACs and PL, FITC-dex extravasation, and thickness increased in the retinas of the diabetic and Cx43 siRNA-treated rats compared to those of the control rats. CONCLUSIONS: Results indicate that downregulation of Cx43 expression alone induces vascular cell death and promotes vascular permeability in the retina. These findings suggest that diabetes-induced downregulation of Cx43 participates in promoting retinal vascular lesions associated with diabetic retinopathy (DR).

Effects of high glucose-induced Cx43 downregulation on occludin and ZO-1 expression and tight junction barrier function in retinal endothelial cells.

PURPOSE: To investigate whether high glucose (HG)-induced downregulation of connexin 43 (Cx43), a gap junction protein, alters ZO-1 and occludin expression and cell monolayer permeability. METHODS: Rat retinal endothelial cells (RRECs) were grown in normal (N; 5 mM) medium, high glucose (HG; 30 mM) medium, N medium transfected with Cx43 siRNA, or N medium transfected with scrambled siRNA. To determine Cx43, occludin, and ZO-1 protein expression, Western blot (WB) analysis and immunostaining were performed. Gap junction intercellular communication (GJIC) was determined using scrape load dye transfer (SLDT) assay. In parallel, cell monolayer permeability was assessed in the four groups of cells, and in cells transfected with Cx43 plasmid or dominant negative Cx43 plasmid. RESULTS: Connexin 43 protein expression was significantly reduced in cells grown in HG (67 ± 15% of control), and a significant reduction in Cx43 was achieved when cells grown in N medium were transfected with Cx43 siRNA (76 ± 12% of control), with concomitant decrease in GJIC activity. Cells grown in HG showed significant reduction in occludin (77 ± 9% of control) and ZO-1 (80 ± 11% of control) protein level compared with cells grown in N media. Importantly, cells transfected with Cx43 siRNA and grown in N medium showed significant downregulation in occludin (78 ± 8% of control) and ZO-1 (81 ± 6% of control) expression, and exhibited increased cell monolayer permeability. Furthermore, Cx43 upregulation protected cells against HG-induced excess cell monolayer permeability. CONCLUSIONS: Our findings indicate that HG-induced downregulation of Cx43 expression and GJIC may contribute to the breakdown of endothelial barrier tight junctions associated with diabetic retinopathy.

Mitochondrial dysfunction and endoplasmic reticulum stress in diabetic retinopathy: mechanistic insights into high glucose-induced retinal cell death.

Hyperglycemia, a prominent characteristic of diabetes, has been implicated in the apoptotic death of vascular and neuronal cells in the retina. In diabetic retinopathy, mitochondrial dysfunction, endoplasmic reticulum (ER) stress, and subsequent breakdown of cellular homeostasis play a critical role in retinal cell death. In particular, changes in mitochondrial morphology, mitochondrial membrane potential heterogeneity, oxygen consumption rate and protein misfolding are beginning to be recognized as key players in the demise of retinal vascular cells in diabetes. Some of these key changes contribute to oxidative stress and influence ion transport, impacting overall cellular homeostasis. The primary objective of this review is to provide insight into the mechanisms in which high glucose influences two disparate cellular organelles, mitochondria and ER, in promoting apoptotic demise of retinal vascular and neuronal cells in diabetic retinopathy.

Lens dislocation has a possible relationship with laser iridotomy.

We report our recent experience of four eyes with spontaneous lens dislocation in four patients with no history of trauma or any systemic disease associated with zonular dialysis. Lens dislocation developed with 0.5 to 6 months following laser iridotomy. All patients were male and two eyes were complicated with acute primary angle closure glaucoma preoperatively. Case 1 showed bilateral lens dislocation, while cases 2 and 3 involved unilateral lens dislocation. Cases 2 and 3 showed lenses completely dislocated into the vitreous cavity. All cases needed lens removal and scleral fixation of intraocular lenses. Final visual acuity was 1.2 in all cases. We suspect that laser iridotomy may induce localized zonular dialysis that results in progressive zonular weakness, leading to lens dislocation.