Phrenic nerve palsy in patients with neuralgic amyotrophy: case series study.

BACKGROUND: Neuralgic amyotrophy (NA) is a relatively uncommon syndrome causing brachial nerves dysfunction. However, it can also affect other nerves including phrenic nerve, which is often misdiagnosed. CASE REPORT: To determine the incidence and characteristics of phrenic nerve palsy in patients with NA in our population, we analyzed the records of all patients with phrenic nerve palsy and/or NA at the University Hospital and the county hospital within the last 10 years. We found that totally, seven patients were confirmed to have NA and phrenic nerve palsy. All of them are male of average age 51.9 years old (51.9±7.4) and had shortness of breath following shoulder and/or neck pain. All of them had elevated diaphragm found in SNIFF test and/or on chest X-ray. Pulmonary function test done in 6 patients demonstrated restrictive lung disease. Six patients needed long-term bi-level positive airway pressure (BiPAP) treatment but mechanic ventilation was not needed. CLINICAL REHABILITATION IMPACT: Our cohort represents one of the largest case series yet reported for phrenic nerve involvement in NA. Most of these patients have had significant pulmonary compromise in the early stage of onset of shoulder/neck pain requiring ongoing BiPAP and specialist monitoring. Recognition of this subset of patients may further require nerve conduction studies/electromyography and respiratory testing.

Intra-articular Triamcinolone Versus Hyaluronate Injections for Low Back Pain With Symptoms Suggestive of Lumbar Zygapophyseal Joint Arthropathy: A Pragmatic, Double-Blind Randomized Controlled Trial.

OBJECTIVE: The aim of the study was to compare hyaluronate with triamcinolone injections in treating chronic low back pain suggestive of lumbar zygopophyseal joint arthropathy. DESIGN: This was a prospective, double-blind, randomized controlled trial. Thirty subjects were randomly assigned to receive bilateral L3-S1 lumbar zygopophyseal joint injections with triamcinolone (KA) or Synvisc-One (HA). Pain (visual analog scale) and Pain Disability Questionnaire scores at 1, 3, and 6 mos were evaluated. RESULTS: No significant intergroup differences (P > 0.05) in outcomes were noted in the 30 recruited subjects. For KA/HA (baseline; 1 mo; 3 mos; 6 mos), visual analog scale scores were the following: 70 (15)/74 (10); 58 (29)/45 (25); 58 (29)/56 (25); and 59 (28)/63 (24), respectively. Pain Disability Questionnaire scores were the following: 100 (23)/102 (28); 77 (30)/74 (34); 87 (26)/74 (36); and 96 (25)/79 (25). Overall percent improvement at 6 mos for KA was 51 (35) and for HA was 42 (33) (P = 0.51). Synvisc-One group visual analog scale scores improved significantly (70 [20]-45 [25] at 1 mo, P = 0.008). Pain Disability Questionnaire scores improved at 1 mo (100 [23]-77 [30], P = 0.009) in the KA group and at all time points in the HA group (102 [28]-74 [34] at 1 mo, P = 0.002; 74 [36] at 3 mos, P = 0.037; 79 at 6 mos [median = 52-99.5], P < 0.001). Medians and quartiles were used in statistical analysis when data did not pass normality. CONCLUSIONS: Patients with chronic low back pain suggestive of lumbar lumbar zygopophyseal joint arthropathy responded similarly to triamcinolone or hyaluronate injections. Synvisc-One group showed significant short- and long-term functional improvement and short-term pain improvement; KA group showed only significant short-term functional benefit and no significant short- or long-term pain improvement.

Does lumbar dorsal ramus syndrome have an objective clinical basis?

BACKGROUND: Degenerative processes can cause chronic low back pain that occasionally creates impingement of the lumbar dorsal rami, resulting in a clinical syndrome previously described as lumbar dorsal ramus syndrome (LDRS). OBJECTIVES: To evaluate the clinical basis of LDRS by comparing pain, disability, and objective measures of pathophysiology in 3 groups of subjects defined by needle electromyography examination (NEE) findings. DESIGN: Prospective group cohort study with retrospective chart review. SETTING: Veterans Affairs medical center outpatient clinic. PATIENTS: Subjects who had undergone lower limb NEE and lumbar magnetic resonance imaging. METHODS: A total of 71 subjects' records that met the study criteria were retrospectively reviewed for interventional spine procedures performed and to measure the lumbosacral paraspinal cross-sectional area (PSP CSA); 28 of the 71 subjects underwent further clinical assessment. One-way analysis of variance was performed to evaluate group differences. MAIN OUTCOME MEASUREMENTS: In the retrospective arm: (1) PSP CSAs measured at 4 lower lumbar disk levels (average of 3 consecutive slices/level) bilaterally and overall left and right lumbar average PSP CSA and (2) the frequency and type of interventional spine procedures performed. In the prospective arm: (1) temporal changes of NEE abnormalities, (2) pain measured using the Visual Analog Scale, (3) Pain Disability Questionnaire responses, and (4) Short Form-36 scores. RESULTS: The right L5 CSA was significantly greater in the group with mechanical low back pain compared with the group with lumbar radicular syndrome (F = 3.3; P < .05). No significant group differences were noted in the number of spine procedures performed. No significant differences in pain or disability scores were found among the groups. NEE findings improved over time predominantly in the LDRS group. CONCLUSIONS: LDRS is a diagnosis with identifiable NEE (lumbar multifidus denervation) findings and magnetic resonance imaging findings that may include lower lumbar paraspinal atrophy. NEE (paraspinal denervation) findings in persons with LDRS may change over time, and the clinical relevance of LDRS to pain, functional disability, and treatment response is unclear.

Role of electrodiagnosis in patients being considered for epidural steroid injections.

Electrodiagnostic (EDX) evaluation, and, more specifically, electromyography (EMG), has a well-established role in the diagnostic confirmation of cervical and lumbar radiculopathy. The role of EMG in prognostication, however, is less established and remains a topic of debate. The purpose of this article is to evaluate the diagnostic and prognosticating role of EMG in cervical and lumbar radiculopathies, and to assess the utility of EMG in predicting outcomes after epidural steroid injections (ESI). A review of the existing literature strongly supports a prognosticating role for EDX in predicting outcomes after lumbar ESI in lumbosacral radiculopathies (LSR). Although limited research regarding outcome prediction after cervical ESI in cervical radiculopathies has been performed, no study has specifically evaluated the utility of EMG in predicting outcomes for cervical ESI, and this topic requires further investigation. An EDX evaluation can provide clinicians with accurate and reliable diagnostic information (level I or level II evidence) in the evaluation of patients with lumbosacral radiculopathies, and can provide more valid prognostic information (level I evidence) regarding potential benefits of lumbar ESI. An EDX evaluation, therefore, can enhance a clinician's ability to advise patients on the most appropriate and efficacious evaluation and management plan for the treatment of painful radiculopathies.

Needle electromyography predicts outcome after lumbar epidural steroid injection.

INTRODUCTION: Needle electromyography (NEE) would be more valuable if it could predict outcomes after lumbar epidural steroid injections (LESIs) in lumbosacral radiculopathy (LSR). METHODS: We investigated the predictive value of NEE for outcome after LESI compared with other known predictive variables in 89 subjects with clinical LSR. Seventy patients completed the study, which included diagnostic lower extremity NEE and LESI. Outcome measures included changes in pain, physical function, and psychosocial function [assessed using the Pain Disability Questionnaire (PDQ)]. RESULTS: NEE was an independent predictor of long-term pain improvement after LESI and was not predictive of PDQ functional improvement. A regression model, with NEE as one of several independent variables, showed strong outcome-predictive ability. CONCLUSIONS: NEE is an independent predictor of long-term pain relief after LESI for LSR. Abnormal NEE is predictive of better outcome than normal NEE. A regression equation including NEE and other independent predictors was predictive of pain and functional outcomes.

Interrater reliability of needle electromyographic findings in lumbar radiculopathy.

OBJECTIVE: This study was performed to investigate the interrater reliability of needle electromyographic findings and electrodiagnostic impressions among expert electrodiagnosticians. DESIGN: Twenty-nine electromyographic recordings were chosen for this study from a larger prospective, observational cohort of 89 consecutive subjects, who were referred for electrodiagnostic evaluation of the lower limbs in a hospital-based spine clinic. The parent study was designed to evaluate the utility of electrodiagnostic findings in predicting outcomes after epidural steroid injections in lumbar radiculopathy. An unmasked, American Board of Electrodiagnostic Medicine board-certified examiner with knowledge of the patient's history and physical examination performed all initial electrodiagnostic evaluations, including needle electromyographic examination of a standardized set of six limb muscles and lumbar paraspinals representing L3 through S1 myotomes. The insertional and spontaneous activities of all muscles were recorded as de-identified digital video files with only muscle names visible. Motor units were not analyzed. Two independent, American Board of Electrodiagnostic Medicine board-certified examiners, who were masked to the patient's name, history, physical examination, and the electrodiagnostic report, reviewed 29 study subjects' digital video files. They rated each muscle's insertional and spontaneous activity on a standardized scoring sheet. After the examination was scored, they also generated a diagnostic impression of no evidence, possible evidence, or clear evidence of lumbar radiculopathy. Interrater reliability between the unmasked examiner and the two independent, masked examiners was assessed by Cohen's kappa statistic for electromyographic scoring of the muscles examined and for diagnostic impression. RESULTS: The interrater reliability was substantial (kappa >0.60) showing >60% agreement for the scoring of most of the muscles examined. The overall diagnostic impression showed outstanding interrater reliability (kappa >0.90) showing >90% agreement between the unmasked and masked examiners. There were no significant differences in the scoring between the two masked examiners. CONCLUSIONS: Needle electromyographic assessment of lower-limb and lumbar paraspinal muscles in the electrodiagnostic evaluation of lumbar radiculopathy is objective and highly reliable when performed by well trained and qualified electromyographers. Masked validation can be performed in electromyographic-based research.

Early intervention options for acute low back pain patients: a randomized clinical trial with one-year follow-up outcomes.

INTRODUCTION: In an earlier study, Gatchel et al. (J Occup Rehabil 13:1-9, 2003) demonstrated that participants at high risk for developing chronic low back pain disability (CLBPD), who received a biopsychosocial early intervention treatment program, displayed significantly more symptom improvement, as well as cost savings, relative to participants receiving standard care. The purpose of the present study was to expand on these results by examining whether the addition of a work-transition component would further strengthen the effectiveness of this early intervention treatment. METHODS: Using an existing algorithm, participants were identified as being high-risk (HR) or low-risk (LR) for developing CLBPD. HR participants were then randomly assigned to one of three groups: early intervention (EI); early intervention with work transition (EI/WT); or standard care (SC). Participants provided information regarding pain, disability, work status, and psychosocial functioning at baseline, periodically during treatment, and again 1 year following completion of treatment. RESULTS: At 1-year follow-up, no significant differences were found between the EI and EI/WT groups in terms of occupational status, self-reports of pain and disability, coping ability or psychosocial functioning. However, significant differences in all these outcomes were found comparing these groups to standard care. CONCLUSION: The addition of a work transition component to an early intervention program for the treatment of ALBP did not significantly contribute to improved work outcomes. However, results further support the effectiveness of early intervention for high-risk ALBP patients.

A cost utility analysis of interdisciplinary early intervention versus treatment as usual for high-risk acute low back pain patients.

Chronic pain is a costly and debilitating condition that has proven difficult to treat, solely with medical interventions, due to the complex interplay of biological, psychological, and social factors in its onset and persistence. Many studies have demonstrated the effectiveness of interdisciplinary treatment that includes psychosocial interventions for low back pain. Nevertheless, these interventions continue to be under-utilized due to concerns of cost and applicability. The present study utilized a cost utility analysis to evaluate effectiveness and associated costs of interdisciplinary early intervention for individuals with acute low back pain that was identified as high-risk for becoming chronic. Treatment effectiveness was evaluated using a standard pain measure and quality-adjusted life years, and associated medical and employment costs were gathered for 1 year. Results indicated that subjects improved significantly from pretreatment to 1-year follow-up, and that the early intervention group reported fewer health-care visits and missed workdays than the treatment as usual group. The majority of 1,000 bootstrapped samples demonstrated the dominance of the early intervention program as being both more effective and less costly from a societal perspective. The early intervention treatment was the preferred option in over 85% of samples within an established range of acceptable costs. These results are encouraging evidence for the cost-effectiveness of interdisciplinary intervention and the benefits of targeted early treatment.