Carboplasty, a Simple Tibial Marrow Technique for Knee Osteoarthritis: A Placebo-Controlled Randomized Trial.

Background: Carboplasty is a new minimally invasive technique for knee osteoarthritis (OA) that consists of injecting tibial marrow aspirate into the bone-cartilage interface as well as intra-articularly. Purpose: To compare the clinical and imaging outcomes, as well as the safety, of carboplasty for symptomatic knee OA in a placebo-controlled trial. Study Design: Randomized controlled trial; Level of evidence, 1. Methods: The authors conducted a randomized controlled trial to compare carboplasty with placebo for the treatment of symptomatic knee OA. Patients who had failed medical treatment and had bone edema on magnetic resonance imaging (MRI) were randomized in a 1:1 ratio to carboplasty or placebo. The primary outcome of the study was the Numeric Pain Rating Scale (NPRS) for the knee at 1 year (scores range from 0 to 10, with a higher score indicating worse pain). Secondary outcomes were the Knee injury and Osteoarthritis Outcome Score (KOOS), treatment responder rate (based on achieving the minimal clinically important difference of the NPRS), MRI bone edema reduction, and treatment safety. Results: In total, 50 patients (25 carboplasty vs 25 placebo) were enrolled and followed up with for an average of 18 months (range, 14-24 months). The average NPRS at baseline decreased from 7.1 ± 0.9 to 2.9 ± 2.1 (P < .001) at 1 year in the carboplasty group and from 7.7 ± 0.9 to 4.9 ± 2.2 (P < .001) in the placebo group. On average, patients after carboplasty improved 60% from their initial NPRS, and patients after placebo improved 37% (P = .003). Patients had a statistically significantly greater improvement from baseline in all KOOS subscales in the carboplasty group compared with the placebo group (P < .001). The responder rates were 96% for carboplasty and 76% for placebo (P = .098). Bone edema was reduced in 72% of patients in the carboplasty group and 44% of patients in the placebo group (P = .045). Neither group had adverse events related to treatment. Conclusion: Carboplasty resulted in greater pain reduction, a significantly greater improvement in all KOOS subscales, and a similar safety profile compared with placebo in patients with symptomatic knee OA and bone edema. Registration: ISRCTN69838191 (ISRCT Registry).

"Back Rx, a personalized mobile phone application for discogenic chronic low back pain: a prospective pilot study".

BACKGROUND: Intervertebral disc pathology is the most common identifiable cause of chronic lower back pain (CLBP). There are limited conservative alternatives to treat discogenic axial CLBP. Back Rx is a mobile application (app) developed to treat patients with this condition, following the Back Rx exercise program, assisted by a virtual coach. METHODS: Patients 18 to 65 years of age, with axial CLBP (more than 3 months), and evidence of lumbar disc pathology by magnetic resonance imaging (MRI) were enrolled to the study. Patients' symptomatology was prospectively evaluated at baseline and after 3 months of using the Back Rx app. The main outcome of the study was back pain evaluated using the visual analog scale (VAS) for pain. Secondary outcomes were the patient's functionality, the weekly pain medication intake, the patients' adherence to the app, and the patients´ satisfaction rate. RESULTS: Seventy-five patients with CLBP were enrolled in the study. All patients had a statistically significant improvement from baseline to final follow-up in the average VAS scores, and the functionality evaluations. Average VAS scores decreased from 5.17 ± 2.1 at baseline to 3.8 ± 2.6 at final follow-up (P = 0.016). Patients showed a significant decrease in the number of pain medications taken during a week (P = 0.001). Overall compliance with the app was 52%, and 65% of the patients rated the overall experience as good or excellent. CONCLUSION: The Back Rx app decreased pain and increased function in patients with discogenic axial CLBP compared to their baseline status. Further measures are needed to increase patients' compliance with the app and the Back Rx program. TRIAL REGISTRATION: Retrospectively registered in 2/2/2017 NCT03040310 (ClinicalTrials.gov).

Epidural Steroid Injections Acutely Suppress Bone Formation Markers in Postmenopausal Women.

CONTEXT: Over 9 million epidural steroid injections (ESIs) are performed annually in the United States. Although these injections effectively treat lumbar radicular pain, they may have adverse consequences, including bone loss. OBJECTIVE: To investigate acute changes in bone turnover following ESI. We focused on postmenopausal women, who may be at greatest risk for adverse skeletal consequences due to the combined effects of ESIs with aging and estrogen deficiency. METHODS: Single-center prospective observational study. Postmenopausal women undergoing lumbar ESIs and controls with no steroid exposure were included. Outcomes were serum cortisol, markers of bone formation, osteocalcin, and procollagen type-1 N-terminal propeptide (P1NP), and bone resorption by C-telopeptide (CTX) measured at baseline, 1, 4, 12, 26, and 52 weeks after ESIs. RESULTS: Among ESI-treated women, serum cortisol declined by ~50% 1 week after injection. Bone formation markers significantly decreased 1 week following ESIs: osteocalcin by 21% and P1NP by 22%. Both markers remained suppressed at 4 and 12 weeks, but returned to baseline levels by 26 weeks. There was no significant change in bone resorption measured by CTX. Among controls, there were no significant changes in cortisol or bone turnover markers. CONCLUSION: These results provide evidence of an early and substantial reduction in bone formation markers following ESIs. This effect persisted for over 12 weeks, suggesting that ESIs may have lasting skeletal consequences. Given the large population of older adults who receive ESIs, further investigation into the long-term skeletal sequelae of these injections is warranted.

An mHealth App for Self-Management of Chronic Lower Back Pain (Limbr): Pilot Study.

BACKGROUND: Although mobile health (mHealth) interventions can help improve outcomes among patients with chronic lower back pain (CLBP), many available mHealth apps offer content that is not evidence based. Limbr was designed to enhance self-management of CLBP by packaging self-directed rehabilitation tutorial videos, visual self-report tools, remote health coach support, and activity tracking into a suite of mobile phone apps, including Your Activities of Daily Living, an image-based tool for quantifying pain-related disability. OBJECTIVE: The aim is to (1) describe patient engagement with the Limbr program, (2) describe patient-perceived utility of the Limbr program, and (3) assess the validity of the Your Activities of Daily Living module for quantifying functional status among patients with CLBP. METHODS: This was a single-arm trial utilizing a convenience sample of 93 adult patients with discogenic back pain who visited a single physiatrist from January 2016 to February 2017. Eligible patients were enrolled in 3-month physical therapy program and received the Limbr mobile phone app suite for iOS or Android. The program included three daily visual self-reports to assess pain, activity level, and medication/coping mechanisms; rehabilitation video tutorials; passive activity-level measurement; and chat-based health coaching. Patient characteristics, patient engagement, and perceived utility were analyzed descriptively. Associations between participant characteristics and program interaction were analyzed using multiple linear regression. Associations between Your Activities of Daily Living and Oswestry Disability Index (ODI) assessments were examined using Pearson correlation and hierarchical linear modeling. RESULTS: A total of 93 participants were enrolled; of these, 35 (38%) completed the program (age: mean 46, SD 16 years; female: 22/35, 63%). More than half of completers finished assessments at least every 3 days and 70% (19/27) used the rehabilitation component at least once a week. Among respondents to a Web-based feedback survey, 76% (16/21) found the daily notifications helped them remember to complete their exercises, 81% (17/21) found the system easy to use, and 62% (13/21) rated their overall experience good or excellent. Baseline Your Activities of Daily Living score was a significant predictor of baseline ODI score, with ODI increasing by 0.30 units for every 1-unit increase in Your Activities of Daily Living (P<.001). Similarly, hierarchical linear modeling analysis indicated that Your Activities of Daily Living daily assessment scores were significant predictors of ODI scores over the course of the study (P=.01). CONCLUSIONS: Engagement among participants who completed the Limbr program was high, and program utility was rated positively by most respondents. Your Activities of Daily Living was significantly associated with ODI scores, supporting the validity of this novel tool. Future studies should assess the effect of Limbr on clinical outcomes, evaluate its use among a wider patient sample, and explore strategies for reducing attrition. TRIAL REGISTRATION: ClinicalTrials.gov NCT03040310; https://clinicaltrials.gov/ct2/show/NCT03040310 (Archived by WebCite at http://www.webcitation.org/722mEvAiv).

Appropriate Use Criteria for Hyaluronic Acid in the Treatment of Knee Osteoarthritis in the United States.

OBJECTIVE: A workgroup of clinical experts has developed an Appropriate Use Criteria (AUC) for the use of hyaluronic acid (HA) in the treatment of osteoarthritis (OA) of the knee. The increasingly broad and varied use of HA injections, lack of published clinical guidance, and limited coverage for their use has created the imperative to establish appropriateness criteria. METHODS: The experts of this workgroup represent rheumatology, orthopedic surgery, physiatry, sports medicine, and nursing clinicians with substantive knowledge of intra-articular HA therapy. This workgroup utilized the results of a systematic review of evidence, expert clinical opinion, and current evidence-based clinical practice guidelines to develop appropriateness criteria for the use of intra-articular HA for knee OA in 17 real-world clinical scenarios. RESULTS: The workgroup scored the appropriateness of treatment of each patient scenario using a 9-point scale to designate a treatment as appropriate (7-9), uncertain (4-6), or inappropriate (1-3). Six scenarios were scored as appropriate, 10 scenarios were scored as uncertain, and 1 scenario was scored as inappropriate. CONCLUSION: This article can assist clinicians in shared decision-making by providing best practices in considering HA injections for knee OA treatment. Moreover, this AUC article can aid payers and policy makers in determining reimbursement and preauthorization policies and more appropriately managing health care resources. It is clear that further research is still necessary-particularly in patient populations differentiated by OA severity-that may benefit the greatest from the use of HA injections for the treatment of knee OA.

The role of the Back Rx exercise program in diskogenic low back pain: a prospective randomized trial.

OBJECTIVE: To determine the efficacy of the Back Rx program in patients with diskogenic low back pain (LBP). DESIGN: Prospective, randomized study. SETTING: Outpatient setting of a major university teaching hospital. PARTICIPANTS: Subjects with LBP greater than leg pain for at least 3 months duration and magnetic resonance imaging evidence of disk pathology. Fifty of 87 eligible patients consented and were randomized into age- and sex-matched groups. INTERVENTIONS: Group I participated in the Back Rx program for 15 minutes a day, 3 times a week. All patients, from both groups, received celecoxib (200 mg) and hydrocodone (5 mg) with acetaminophen (500 mg) as needed, and wore a lumbar cryobrace for 15 minutes before bedtime. MAIN OUTCOME MEASURES: Roland-Morris Disability Questionnaire score, numeric pain rating score, patient satisfaction score, measured forward flexion, use of celecoxib, hydrocodone, and acetaminophen, time off work, and rate of symptom recurrence. RESULTS: At minimal 12-month follow-up, 70% of group I reported over 50% pain reduction with good or better patient satisfaction, compared with 33% in group II (P=.001). Average daily hydrocodone and acetaminophen use and time off work were less for group I (all, P<.05). Recurrence of symptoms at the end of the year was less for group I (P=.001). CONCLUSIONS: Back Rx exercises, combined with use of a lumbar cryobrace and oral medications, yielded superior therapeutic results than with use of medications and cryobrace alone. Also significant was the reduced rate of recurrence in these patients.

The role of subacromial shoulder irrigation in the treatment of calcific rotator cuff tendinosis: a case series.

OBJECTIVE: To study the efficacy of subacromial shoulder irrigation in the treatment of calcific rotator cuff tendinosis. DESIGN: Consecutive case series. SETTING: Musculoskeletal rehabilitation clinic. PARTICIPANTS: Twenty-eight tennis players (16 women, 12 men; mean age, 44.3y) with calcific rotator cuff tendinosis, who failed conservative measures. INTERVENTION: Subjects underwent fluoroscopically guided subacromial shoulder irrigation (50-75 mL of normal saline in 10 mL aliquots) followed by a corticosteroid injection (5 mL solution of 1 mL triamcinolone [40 mg/mL] and 4 mL of 0.5% bupivacaine). After the procedure, all patients completed the same exercise regimen. MAIN OUTCOME MEASURES: LInsalata Shoulder Rating Questionnaire (LSRQ) score, visual numeric pain score, and patient satisfaction. RESULTS: At 1-year follow-up, 85.7% reported a successful outcome with significant improvements in the LSQR and numeric pain scores. CONCLUSIONS: Our minimally invasive approach was safe, well tolerated, and effective, which should make it useful in providing relief for patients with rotator cuff tendinosis.

Low back pain in professional golfers: the role of associated hip and low back range-of-motion deficits.

BACKGROUND: Low back pain is fairly prevalent among golfers; however, its precise biomechanical mechanism is often debated. HYPOTHESIS: There is a positive correlation between decreased lead hip rotation and lumbar range of motion with a prior history of low back pain in professional golfers. STUDY DESIGN: A cross-sectional study. METHODS: Forty-two consecutive professional male golfers were categorized as group 1 (history of low back pain greater than 2 weeks affecting quality of play within past 1 year) and group 2 (no previous such history). All underwent measurements of hip and lumbar range of motion, FABERE's distance, and finger-to-floor distance. Differences in measurements were analyzed using the Wilcoxon signed rank test. RESULTS: 33% of golfers had previously experienced low back pain. A statistically significant correlation (P <.05) was observed between a history of low back pain with decreased lead hip internal rotation, FABERE's distance, and lumbar extension. No statistically significant difference was noted in nonlead hip range of motion or finger-to-floor distance with history of low back pain. CONCLUSIONS: Range-of-motion deficits in the lead hip rotation and lumbar spine extension correlated with a history of low back pain in golfers.

The role of capsular distention in adhesive capsulitis.

OBJECTIVE: To explore the efficacy of capsular distension in the treatment of adhesive capsulitis of the shoulder joint. DESIGN: Prospective study. SETTING: Musculoskeletal clinic. PARTICIPANTS: Twenty-two patients (18 women, 4 men; mean age, 41.3y; range, 29-54y) with adhesive capsulitis of shoulder joint. Nineteen patients had Hannafin stage II and 3 patients had Hannafin stage III adhesive capsulitis. All patients had continuous pain and significant range of motion (ROM) limitations of the shoulder joint despite a minimum of 3 months of physical therapy (PT). INTERVENTION: Capsular distension with saline under fluoroscopic control, followed by a PT program. MAIN OUTCOME MEASURES: L'Insalata Shoulder Rating Questionnaire (LSRQ) score and Hannafin ROM assessment protocol. RESULTS: In the 19 patients with stage II adhesive capsulitis, the mean LSRQ score and range of abduction improved from predistention values of 49.8 degrees and 87.2 degrees to postdistension mean values of 88.1 degrees and 117.6 degrees at minimum of 1 year postdistention, respectively (P<.05). However, in the 3 patients with stage III adhesive capsulitis, the mean LSRQ score and range of abduction changed from predistention values of 41.2 degrees and 84.1 degrees to postdistension mean values of 57.8 degrees and 90.4 degrees at minimum of 1 year postdistention, respectively (P>.05). CONCLUSIONS: The treatment modality should be individualized on the basis of the stage of the adhesive capsulitis, and the distension procedure should be reserved for patients in stage II who do not progress despite participating in a PT program.

Prevalence of peripheral neurologic injuries in rotator cuff tears with atrophy.

The purpose of this study is to define the prevalence of peripheral nerve injury associated with full-thickness tears of the rotator cuff presenting with shoulder muscle atrophy. Twenty-five patients with the diagnosis of full-thickness rotator cuff tear were included. Electrodiagnostic testing, including nerve conduction studies and needle examination, was performed on all patients. There were 7 abnormal electromyographic examinations. The most common diagnosis was upper trunk brachial plexopathy severely affecting the axillary nerve (4/7), followed by suprascapular neuropathy (2/7) and cervical radiculopathy (1/7). The prevalence of associated peripheral neuropathy was found to be 28%. Greater degrees of atrophy were significantly associated with the presence of neuropathy in these patients. Careful neurologic screening in all patients and electromyographic examination in clinically suspicious groups are recommended in patients with full-thickness cuff tears before surgical repair.

Role of hylan G-F 20 in treatment of osteoarthritis of the hip joint.

OBJECTIVE: To study the efficacy of hylan G-F 20 in the treatment of osteoarthritis (OA) of the hip joint. DESIGN: Prospective within-group study. SETTING: Musculoskeletal rehabilitation clinic. PARTICIPANTS: Twenty-two patients (25 hips) with hip joint OA who had failed to find pain relief from conservative methods such as physical therapy, exercises, and steroid injections. Demographics included 14 men and 11 women (mean age, 56.4y), 21 of whom had mild to moderate OA and 4 of whom had severe OA of the hips. INTERVENTION: Each hip joint was injected with 2mL of hylan G-F 20 at 2, 3, and 4 weeks and fluoroscopic lavage with 100mL of normal saline at week 1. All patients had standard hip exercise regimen after the injection. MAIN OUTCOME MEASURES: American Academy of Orthopaedic Surgeons (AAOS) Lower Limb Core Scale score and visual numeric pain score. RESULTS: At 1-year follow-up, the AAOS Lower Limb Core Scale score improved from a preinjection mean of 44.2 to a follow-up mean of 86.1 (P<.05). The mean visual numeric pain score improved from a preinjection mean of 8.7 (range, 6.4-10) to a follow-up mean of 2.3 (range, 0-7.2). The overall success rate was 84%. In patients with mild to moderate OA, the mean pain score decreased from a preinjection value of 7.8 to a follow-up value of 1.7. The success rate was 90.5% in that subgroup. In patients with severe OA, the mean pain score decreased from a preinjection value of 9.1 to a follow-up value of 3.8. The success rate was 50% in that subgroup. There were no complications related to the injection. CONCLUSION: Use of hylan G-F 20 injection is a viable option for treatment of mild to moderate OA of the hip joint.

Management of knee osteoarthritis: knee lavage combined with hylan versus hylan alone.

OBJECTIVE: To assess the difference in efficacy between knee lavage plus the standard hylan G-F 20 (a derivative of hyaluronan) protocol and the standard hylan G-F 20 as per standard usage protocol alone for the treatment of knee osteoarthritis (OA). DESIGN: Nonrandomized prospective study in which patients chose their treatment group. Follow-up averaged 1.1 years. SETTING: Faculty practice of a single physician at a major teaching hospital. PARTICIPANTS: Eighty-one patients with documented knee OA on magnetic resonance imaging. INTERVENTIONS: Group 1 (n=44) received a single-needle lavage 1 week before the standard hylan G-F 20 protocol; group 2 (n=37) received the standard hylan G-F 20 protocol alone. MAIN OUTCOME MEASURES: Pre- and posttreatment scores on the Lysholm-II Questionnaire and a visual analog scale (VAS) were documented for each patient. The Wilcoxon signed-rank test was used for statistical analysis. RESULTS: A successful outcome was noted in 79.5% of group 1 patients and in 54% of group 2 patients (P<.05). CONCLUSIONS: In the management of knee OA, the use of knee lavage before viscosupplementation with hylan G-F 20 yields better results than using hylan G-F 20 alone. The presence of radiologic grade IV knee OA or moderate to severe patellofemoral arthritis are negative prognostic factors.

Quantitative electromyography analysis of disc unloader brace.

The purpose of this study was to determine if the Disc Unloader brace was effective in reducing intradiscal pressure. There is a strong correlation between lumbar paraspinal activity and intradiscal pressure. We used ten healthy volunteers to measure lumbar paraspinal activity at L5 using a quantitative EMG system. After doing reliability and reproducibility testing which showed margin of error of 7%, ten volunteers were measured for quantitative EMG activity at the L5 paraspinal level in full lumbar flexion without the Disc Unloader brace three times and averaged. The same quantitative EMG testing was done in full flexion with the Disc Unloader brace on at the L5 paraspinal level three times and averaged. For five of the ten patients, we performed the test first with the Disc Unloader brace on whereas for the rest of the five, the test was performed first without the brace on. There were 7 females and 3 males with average age of 39 (range 26-46). The average area under the curve score was 173 +/- 27.1 microvolts at the L5 paraspinal for the ten healthy subjects without the Disc Unloader brace on. The average area under the curve score was 102 +/- 19.6 microvolts at the L5 paraspinal for ten healthy subjects with the Disc Unloader brace on. There was a statistically significant (p<0.05) reduction in quantitative paraspinal activity of 41% with the Disc Unloader brace on. We conclude that the Disc Unloader brace is effective in reducing quantitative EMG lumbar paraspinal myoelectric activity and therefore intradiscal pressures.

Role of radiofrequency denervation in lumbar zygapophyseal joint synovitis in baseball pitchers: a clinical experience.

Lumbar zygapophyseal joints have long been considered a source of low back pain with or without leg pain. The objective of this prospective study was to investigate the therapeutic effectiveness of lumbar zygapophyseal joint radiofrequency denervation (RFD) followed by physical therapy, for the treatment of refractory lumbar zygapophyseal joint mediated low back pain secondary to lumbar zygapophyseal joint synovitis, in baseball pitchers. Participants included twelve male baseball pitchers with a diagnosis of lumbar zygapophyseal joint synovitis mediated low back pain and a subsequent difficulty in pitching. These athletes underwent a trial of treatment, including oral anti-inflammatory medication, physical therapy, osteopathic manipulations, and fluoroscopically guided intra-articular zygapophyseal joint injection utilizing steroid and local anesthetic agent. Failure to progress led to these athletes receiving percutaneous, fluoroscopically-guided, radiofrequency denervation of the bilateral L 4-L5 and L5-S1 zygapophyseal joints. A good response to a diagnostic medial branch block was a prerequisite for RFD treatment. In all cases, the medial branch above and below the involved level was treated. Post procedure, all athletes participated in a phased physical therapy program followed by a progressive return to pitching. Success was defined as the ability to return to pre-procedure level of baseball pitching combined with greater than 50% low back pain reduction. Pre- and post-RFD, Visual Analog (Numeric) Scale (VAS) and Roland-Morris (R-M) tests were administered. Ten out of 12 (83%) athletes were able to return to pitching at a level attained prior to RFD. All 12 patients, experienced statistically significant low back pain relief, with a mean pre-RFD VAS of 8.4; mean post-RFD VAS of 1.7; mean pre-RFD R-M score of 12.3; and mean post-RFD R-M score of 22.3. In conclusion, athletes, experiencing lumbar zygapophyseal joint mediated low back pain secondary to zygapophyseal joint synovitis and have failed more conservative management may benefit from radiofrequency zygapophyseal joint denervation followed by a formal rehabilitation program.

Exercise recommendations in athletes with early osteoarthritis of the knee.

Osteoarthritis of the knee is a common condition that afflicts millions of individuals annually. The benefits of exercise are self evident as athletes and middle-aged individuals grow older, and the focus has centered on pain-free participation in their sports and activities. In the past, medical treatment has primarily relied on oral medications to manage symptoms, without the incorporation of therapeutic exercise. Consequently, as the osteoarthritis progresses, patients are offered surgical management and eventual joint replacement. A goal-oriented progressive rehabilitation programme that incorporates medical management in the initial stages would allow patients a greater ability to participate in sports, thereby obtaining the numerous benefits of exercise and perhaps delaying surgery. A progressive rehabilitation programme consists of five stages (I to V). Medical management is primarily reserved for stage I: protected mobilisation and pain control. It entails the use of pain medications, nonsteroidal anti-inflammatory drugs, with or without the use of chondroprotective agents such as glucosamine. Injection therapy is usually incorporated at this stage with intra-articular injections of corticosteroids or viscosupplementation, either of which may be combined with minimally invasive single-needle closed joint lavage procedure. Stages II and III introduce open kinetic-chain nonweightbearing exercises to the affected joint, with progression to closed kinetic-chain exercises. Stage IV focuses on return to sporting activities, with continued closed kinetic-chain exercises. There is also the incorporation of sport-specific exercises to improve neuromuscular coordination, timing and protect against future injury. Finally, stage V, or the maintenance phase, is primarily aimed at educating the patient on how to reduce the risk of re-injury and optimise their current exercise programme. Medical management of knee osteoarthritis within the framework of a progressive rehabilitation programme that includes active therapeutic exercise may delay the progression of this disease and allow patients years of greater pain-free activity and improved quality of life.

Negative prognostic factors in managing massive rotator cuff tears.

OBJECTIVE: To investigate the negative prognostic factors in the management of massive rotator cuff tears. DESIGN: Retrospective nonrandomized study. SETTING: Faculty Practice associated with a major orthopedic teaching hospital. PATIENTS: 108 patients who were treated for massive rotator cuff tears were evaluated for an average of 3.2 years posttreatment. There were 58 females and 50 males, with a mean age of 61.3 years. INTERVENTIONS: 40 patients underwent conservative nonsurgical management (Group 1), 32 patients underwent arthroscopic debridement (Group 2), and 36 patients underwent primary repair of the rotator cuff (Group 3). MAIN OUTCOME MEASURES: A detailed Shoulder Rating Questionnaire was filled out by patients pretreatment and minimal 2 years posttreatment. RESULTS: Overall, Group 1 had 65% excellent or good outcomes, Group 2 had 81%, and Group 3 had 86%. The subgroup of patients in Group 1 who had cortisone injections had a 75% success rate. CONCLUSIONS: Negative prognostic factors evaluated are presence of glenohumeral arthritis, decreased passive range of motion, superior migration of the humeral head, presence of atrophy, and external rotation/abduction strength less than 3. The presence of 3 or more of these negative prognostic factors are correlated with poor outcomes in the treatment of massive rotator cuff tears.

Transforaminal epidural steroid injections in lumbosacral radiculopathy: a prospective randomized study.

STUDY DESIGN: A prospective study randomized by patient choice from the private practice of a single physician affiliated with a major teaching hospital was conducted. OBJECTIVES: To compare transforaminal epidural steroid injections with saline trigger-point injections used in the treatment of lumbosacral radiculopathy secondary to a herniated nucleus pulposus. SUMMARY OF BACKGROUND DATA: Epidural steroid injections have been used for more than half a century in the management of lumbosacral radicular pain. At this writing, however, there have been no controlled prospective trials of transforaminal epidural steroid injections in the treatment of lumbar radiculopathy secondary to a herniated nucleus pulposus. METHODS: Randomized by patient choice, patients received either a transforaminal epidural steroid injection or a saline trigger-point injection. Treatment outcome was measured using a patient satisfaction scale with choice options of 0 (poor), 1 (fair), 2 (good), 3 (very good), and 4 (excellent); a Roland-Morris low back pain questionnaire that showed improvement by an increase in score; a measurement of finger-to-floor distance with the patient in fully tolerated hip flexion; and a visual numeric pain scale ranging from 0 to 10. A successful outcome required a patient satisfaction score of 2 (good) or 3 (very good), improvement on the Roland-Morris score of 5 or more, and pain reduction greater than 50% at least 1 year after treatment. The final analysis included 48 patients with an average follow-up period of 16 months (range, 12-21 months). RESULTS: After an average follow-up period of 1.4 years, the group receiving transforaminal epidural steroid injections had a success rate of 84%, as compared with 48% for the group receiving trigger-point injections (P < 0.005). CONCLUSION: Fluoroscopically guided transforaminal injections serve as an important tool in the nonsurgical management of lumbosacral radiculopathy secondary to a herniated nucleus pulposus.