Immediate and acute adverse effects following transforaminal epidural steroid injections with dexamethasone.

BACKGROUND: Transforaminal epidural steroid injections (TFESI) are widely used for the conservative treatment of radicular pain. The use of dexamethasone in TFESIs is relatively new; therefore, immediate and acute adverse effects that it may cause are not fully updated. OBJECTIVE: To evaluate immediate and acute adverse effects following TFESI with dexamethasone. STUDY DESIGN: Prospective, observational study. SETTING: A spine center affiliated with a rehabilitation hospital. METHODS: One hundred fifty consecutive patients receiving TFESI for the management of radicular and axial spinal pain at the cervical, lumbar, and sacral levels with dexamethasone using fluoroscopic guidance with digital subtraction technology were enrolled. The occurrence of adverse effects in patients in the 2-week time period following interventions was monitored through a set of questionnaires followed up by phone calls scheduled for 1 day, day 3, and day 14. Intensity and duration of side effects were recorded. RESULTS: Of the 150 patients enrolled, 31 patients (19.5%) experienced adverse effects within the first 30 minutes following the intervention. The most common adverse effects were numbness and tingling in the limb, which developed in 19 patients (11.95%) followed by perineal pruritus that occurred in 7 cases (4.4%). Patients also reported experiencing adverse effects within the 3 days following intervention; most complained of headaches, insomnia, hiccups, flushing, and increased radicular pain. No major complications were noted. LIMITATIONS: The sample size enrolled might be too small to perceive possible rare side effects related to the procedure. The 2-week follow-up period is a limitation for evaluating late side effects. CONCLUSIONS: This study offers provision to interventionalists that TFESI with dexamethasone when performed by experienced hands and with proper technique has minor self-limited transient adverse effects that can be easily managed. Patients should be made aware of these adverse effects and their management. Further larger studies are needed to validate the safe use of dexamethasone and the safety of transforaminal epidural injections.

The lateral atlanto-axial joint as a source of headache in congenital atlanto-occipital fusion.

A 47-yr-old woman presented with severe right-sided neck pain and headache, predominantly in the right-occipital region, for 3 yrs. The symptoms persisted despite using nonsteroidal antiinflammatory medications and undergoing physical therapy. The patient's examination was unremarkable except for reduced neck motion and prominent right-occipital tenderness. Imaging showed congenital fusion of the atlanto-occipital joints bilaterally. A fluoroscopically guided diagnostic right-lateral atlanto-axial joint injection was positive. We are reporting the first case of clinically proven lateral atlanto-axial joint arthropathy with neck pain and headache in a patient with congenital atlanto-occipital joint fusion. Subsequently, the patient received a set of two therapeutic lateral atlanto-axial joint injections. She had remarkable improvement of her headache and neck pain. At 1-yr follow-up, the patient continued to have significant improvement of the right-sided neck pain and headache.

Functionally oriented rehabilitation program for patients with fibromyalgia: preliminary results.

OBJECTIVE: To evaluate function and disability in patients with fibromyalgia before and after participation in a functionally oriented, multidisciplinary, 8-wk treatment program. DESIGN: A total of 23 patients who met American College of Rheumatology criteria for the diagnosis of fibromyalgia were enrolled in the study. Outcome measures included: range of motion, 6-min walk test, a modified Fibromyalgia Impact Questionnaire, a modified SF-36 Physical Functioning Scale, and the Fibromyalgia Health Assessment Questionnaire. Pretreatment and posttreatment scores were analyzed using paired t tests. RESULTS: All subjects completed the program, and there were no reported injuries. Three subjects failed to complete the survey instruments at the conclusion of the study. Intention to treat analysis including these subjects was carried out but did not significantly change results. For the remaining subjects (n = 20), a significant improvement was found on the Physical Functioning Scale (P = 0.01). Trends toward improvement on the Fibromyalgia Impact Questionnaire (P = 0.40) and Fibromyalgia Health Assessment Questionnaire (P = 0.14) were seen but did not achieve statistical significance. Range of motion testing revealed significant improvements in lumbar spine extension (P < 0.001), straight-leg raise (P < 0.001), cervical spine flexion (P < 0.01), cervical spine rotation (P < 0.05), and cervical spine side bending (P < 0.05). Distance traveled during the 6-min walk test increased significantly (P < 0.01), whereas perceived exertion as measured by the Borg scale did not change. There were no injuries or other adverse consequences of the program. CONCLUSIONS: This study utilized multiple functional outcome measures to demonstrate improved function and decreased disability in patients with fibromyalgia. Our patients reported significantly improved physical function after participation in the 8-wk intensive multidisciplinary treatment program. This progressive, functionally based exercise training program was well tolerated by all participants and outlines an effective exercise prescription for patients with fibromyalgia. Fibromyalgia patients in this study responded favorably to a treatment program that focused on function instead of pain.

Safety and efficacy of percutaneous neuromodulation therapy in the management of subacute radiating low back pain.

OBJECTIVE: Percutaneous neuromodulation therapy (PNT) is a new minimally invasive, office-based treatment for low back pain in which electrical stimulation is delivered to the paraspinal peripheral nerves. The purpose of this study was to determine the safety, tolerability, and clinical efficacy of PNT in a population of patients with subacute low back pain with radiation to the lower extremity. DESIGN: Open label prospective clinical trial. SETTING: Multi-center outpatient setting. PARTICIPANTS: We enrolled 83 patients who had radiating low back pain for 4 weeks to 6 months with a pain intensity of at least 4 on a visual analog scale of 0-10. INTERVENTIONS: Subjects were treated with PNT 1 to 2 times per week for at least 4 weeks. Based on clinical response patients were treated up to an additional 8 weeks. MAIN OUTCOME MEASURES: We recorded baseline visual analog scale (VAS) scores of radiating pain, low back pain, physical activity, and sleep, as well as the Oswestry Disability Questionnaire. Follow-up assessments were performed at each session, and at 5 and 12 weeks. Patients benefiting from treatments at 12 weeks were followed-up at 6 months. RESULTS: Fifty-nine patients completed the study protocol. Mean VAS scores improved as follows: leg/buttock pain decreased by 37% to 4.0 +/- 2.6 from a baseline of 6.6 +/- 1.7 (P < 0.001); low back pain decreased by 26% to 3.9 +/- 2.4 from a baseline of 5.5 +/- 2.2 (P < 0.001); activity levels improved by 38% to 3.6 +/- 2.2 from a baseline of 6.0 +/- 2.2 (P < 0.001); and sleep improved by 27% to 3.1 +/- 2.5 from a baseline of 4.8 +/- 3.0 (P < 0.001). The Oswestry Low Back Pain Disability scores improved by 24% to 32 +/- 16 from a baseline of 43 +/- 15 (P < 0.001). Pain relief was sustained over a 3-month observation period. CONCLUSION: For many patients with subacute radiating low back pain, PNT significantly reduced pain and self-rated disability, and improved sleep quality and activity level. PNT is safe and generally well tolerated.