What will help my practice? David E. Fish, MD, MPH Professor, Department of Orthopaedics Physical Medicine and Rehabilitation, The UCLA Spine Center UCLA

What will help my practice?What will help my practice?

David E. Fish, MD, MPHProfessor, Department of Orthopaedics

Physical Medicine and Rehabilitation, The UCLA Spine Center

UCLA School of Medicine

AAPM&R Best Pain and Spine Papers

David E. Fish, MD, MPH

Physical Medicine and Rehabilitation

Department of Orthopeadic Surgery

Influence Of Low Back Pain And Influence Of Low Back Pain And Prognostic Value Of MRI In Prognostic Value Of MRI In Sciatica Patients In Relation To Sciatica Patients In Relation To Back PainBack Pain

Study # 1Study # 1

• Influence of low back pain and prognostic value of MRI in sciatica patients in relation to back pain.

• el Barzouhi A

• PLoS One. 2014 Mar 17;9(3):e90800. doi: 10.1371/journal.pone.0090800. eCollection 2014.

PurposePurpose

It is not known whether there are prognostic relevant differences in Magnetic Resonance Imaging (MRI) findings between sciatica patients with and without disabling back pain.

MethodsMethods

The MRI findings were compared between sciatica patients with and without disabling back pain

Two neuroradiologists and one neurosurgeon independently evaluated all MR images.

The presence of disabling back pain at baseline was correlated with perceived recovery at one year.

ResultsResults

379 sciatica patients, 158 (42%) had disabling back pain.

Of the patients with both sciatica and disabling back pain 68% did reveal a herniated disc with nerve root compression on MRI..

ResultsResults

The existence of disabling back pain in sciatica at baseline was negatively associated with perceived recovery at one year

(Odds ratio [OR] 0.32 95% Confidence Interval 0.18-0.56, P<0.001).

ResultsResults

Sciatica patients with disabling back pain in absence of nerve root compression on MRI

at baseline reported less perceived recovery at one year

compared to those with predominantly sciatica and nerve root compression on MRI.

(50% vs 91%, P<0.001)

Is this good science?Is this good science?

Hells Yeah it is!!!Hells Yeah it is!!!

Is it important to PMR?Is it important to PMR?

Without a doubt !!!Without a doubt !!!

How will it change me and my How will it change me and my practice with patients?practice with patients?

You can’t judge a person’s emotional state with perceived pain and what is seen on an MRI.You can’t judge a person’s emotional state with perceived pain and what is seen on an MRI.

One must methodically go through the work up and conservative treatmentOne must methodically go through the work up and conservative treatment

Give a person time to recover with therapy, medications, epidurals, and time.Give a person time to recover with therapy, medications, epidurals, and time.

Have the surgical option for a neurological deficit.Have the surgical option for a neurological deficit.

Consider more psychological screening and treatment in an individual with a ‘normal’ MRI.Consider more psychological screening and treatment in an individual with a ‘normal’ MRI.

PAIN AS A DISEASEPAIN AS A DISEASE

Diagnostic Accuracy Of History Taking To Assess Lumbosacral Nerve Root Compression

Study # 2Study # 2

• Diagnostic accuracy of history taking to assess lumbosacral nerve root compression

• Verwoerd AJ

• Spine J. 2014 Sep 1;14(9):2028-37. doi: 10.1016/j.spinee.2013.11.049. Epub 2013 Dec 8.

PurposePurpose

To assess the diagnostic accuracy of history taking

for the presence of lumbosacral nerve root compression or disc herniation

on magnetic resonance imaging in patients with sciatica.

MethodsMethods

395 adult patients with severe disabling radicular leg pain of 6 to 12 weeks duration were included

History was broken out to a standardized protocol of 20 questions to find what contributed in diagnosing nerve root compression

Examples: "male sex," "pain worse in leg than in back," "a non-sudden onset." "body mass index <30," "sensory loss."

MethodsMethods

Age > 40 yearsAge > 40 yearsMale sexMale sexBMI >30BMI >30Intellectual jobIntellectual jobPhysically heavy jobPhysically heavy jobSmokingSmokingDuration of pain for > 9 weeksDuration of pain for > 9 weeksLeg pain duration in weeksLeg pain duration in weeksPain worse in leg than backPain worse in leg than backBack pain > 12 weeksBack pain > 12 weeksSudden OnsetSudden OnsetPrevious leg painPrevious leg painSubjective sensory lossSubjective sensory lossSubjective muscle weaknessSubjective muscle weakness

ResultsResults

ConclusionConclusion

Few history items used in isolation have a diagnostic value to predict MRI disk herniation and nerve root compression. Few history items used in isolation have a diagnostic value to predict MRI disk herniation and nerve root compression.

Diagnostic accuracy of history taking is limited.Diagnostic accuracy of history taking is limited.

The evidence to base diagnostic history and physical exam with sciatica remains limitedThe evidence to base diagnostic history and physical exam with sciatica remains limited


Unfortunately.Unfortunately.


AbsolutelyAbsolutely


You got me…You got me…

Thoracic interlaminar epidural injections in managing chronic thoracic pain: a randomized, double-blind, controlled trial with a 2-year follow-up.

Study # 3Study # 3

• Manchikanti L

• Pain Physician. 2014 May-Jun;17(3):E327-38.

BackgroundBackground

The prevalence of thoracic pain in approximately 13% of the general population compared to 32% of the population with neck pain and 43% of the population with low back pain

Interventions in managing chronic thoracic pain are also less frequent, leading to the paucity of literature about various interventions in managing chronic thoracic pain

Interventions in managing chronic thoracic pain are also less frequent, leading to the paucity of literature about various interventions in managing chronic thoracic pain

PurposePurpose

Assess the effectiveness of thoracic interlaminar epidural injections

in providing effective pain relief and improving function

in patients with chronic mid and/or upper back pain.

MethodsMethods

A randomized, double-blind, active controlled trial.

110 participants divided into 2 groups

1.ESI with local anesthetic alone2.ESI with steroid (Bethamethasone 6mg)

Outcome MeasuresOutcome Measures

Oswestry Disability Index

Employment status

Opioid Intake (morphine equivalents)

Greater than 3 weeks of ‘significant’ improvement with first 2 procedures were considered success

Significant = > 50% decrease in scores at 3, 6, 12, 18, and 24 months

MethodsMethods

Inclusion CriteriaInclusion Criteriano facet joint pain based on blocksno facet joint pain based on blocks18 years or older18 years or olderpain duration for more than 6 monthspain duration for more than 6 monthsfailed conservative carefailed conservative care

Exclusion CriteriaExclusion Criteriafacet joint painfacet joint painunstable or uncontrolled opioid useunstable or uncontrolled opioid useuncontrolled psychiatric issuesuncontrolled psychiatric issuesuncontrolled medial illnessuncontrolled medial illnesslarge disc herniation with spinal cord compressionlarge disc herniation with spinal cord compressionactive infectionactive infection

MethodsMethods

Injection done as an interlaminar approachInjection done as an interlaminar approach

facet blocks done to determine pain generatorfacet blocks done to determine pain generator

sedation for the injectionsedation for the injection

pain complaint pattern with clinical and imagingpain complaint pattern with clinical and imaging

repeated ESI only when pain increasedrepeated ESI only when pain increased

The level of success reduced to below 50%The level of success reduced to below 50%

ResultsResults

Groups 1 and 2 : Groups 1 and 2 : 71% and 81% significantly improved71% and 81% significantly improved2 year follow up2 year follow up

CharacteristicsCharacteristics5 to 6 ESI over 2 years5 to 6 ESI over 2 yearsReliefRelief in weeks in weeksGroup 1: Group 1: 80 weeks80 weeksGroup 2: Group 2: 78 weeks78 weeks

ResultsResults

ESI levelsESI levels

T9-T10T9-T10 30%30%

T10-T11T10-T11 31%31%

T8-T9T8-T9 17%17%

OthersOthers 6% 6%

ResultsResults

ResultsResults


I don’t know… I don’t know… I must beI must be

doing something wrongdoing something wrong

based on these results…based on these results…

Is This Good Science?Is This Good Science?

High success rateHigh success rate

Significant number of opiate reductionsSignificant number of opiate reductions

I don’t see that much thoracic painI don’t see that much thoracic pain

No indication of compression fracturesNo indication of compression fractures

The steroid group did as well as local onlyThe steroid group did as well as local only

Is This Good Science?Is This Good Science?

Authors admit that mechanism of efficacy is unclear.Authors admit that mechanism of efficacy is unclear.

Authors indicate that the results are similar to cervical and lumbar result in literatureAuthors indicate that the results are similar to cervical and lumbar result in literature

The success is based on first two injections and if no success, ESI were not continued.The success is based on first two injections and if no success, ESI were not continued.

No Placebo group… is local a placebo?No Placebo group… is local a placebo?


Definitely because I am Definitely because I am inadequate.inadequate.

Transforaminal ThoracicTransforaminal Thoracic


I may stop doing bilateral TFESII may stop doing bilateral TFESI

I may stop using steroids.I may stop using steroids.

I am sending all patients to I am sending all patients to KentuckyKentucky for shots! for shots!

Does the presence of the fibronectin-aggrecan complex predict outcomes from lumbar discectomy for disc herniation?

Study # 4Study # 4

• Does the presence of the fibronectin-aggrecan complex predict outcomes from lumbar discectomy for disc herniation?

• Smith MW

• Spine J. 2013 Nov 13. pii: S1529-9430(13)00767-5. doi: 10.1016/j.spinee.2013.06.064.


• Protein biomarkers associated with lumbar disc disease have been studied as diagnostic indicators and therapeutic targets.

• A cartilage degradation product, the fibronectin-aggrecan complex (FAC) identified in the epidural space, has been shown to predict response to lumbar epidural steroid injection.


• Protein biomarkers associated with lumbar disc disease have been studied as diagnostic indicators and therapeutic targets.

• Numerous disease-modifying therapies have been proposed to intervene in this cascade, including antibody therapies, stem cell and cellular therapies, and gene therapies


• A complex molecular and cellular cascade of disc degeneration has been elucidated, which involves inflammatory mediators

cytokines, nitric oxide, and signal transduction pathways

structural proteins and their degradation fragments (e.g., fibronectin, aggrecan, and collagens)

proteases/protease inhibitors (e.g., matrix metalloproteinases

[MMPs] and aggrecanases).1–6

PurposePurpose

Determine the ability of FAC to predict response to microdiscectomy for patients with radiculopathy due to lumbar disc herniation

MethodsMethods

Intraoperative sampling was done via lavage of the excised fragment by ELISA for presence of FAC.

92 consecutive patients who opted for microdiscectomy to treat lumbar or lumbosacral radiculopathy 92 consecutive patients who opted for microdiscectomy to treat lumbar or lumbosacral radiculopathy caused by a lumbarcaused by a lumbardisc herniation.disc herniation.

MethodsMethods

excluded criteria:excluded criteria:

plain radiography demonstrating severe loss of disc heightplain radiography demonstrating severe loss of disc height

high-grade degenerative disc diseasehigh-grade degenerative disc disease

spondylolisthesis greater than grade Ispondylolisthesis greater than grade I

Prior lumbar surgery or traumaPrior lumbar surgery or trauma

physical examination revealing weakness in a distributionphysical examination revealing weakness in a distribution

inconsistent with the MRIinconsistent with the MRI

Diagnosis of inflammatory arthritidesDiagnosis of inflammatory arthritides

crystalline arthropathies or other rheumatologic diseasescrystalline arthropathies or other rheumatologic diseases

red flags:red flags:progressive weaknessprogressive weaknessbowel or bladder complaintsbowel or bladder complaintsunknown radiographic mass unknown radiographic mass unexpected weight lossunexpected weight loss

ResultsResults

75 individuals75 individuals

At 3-month follow-up, 57 (76%) patents were "better."

There was a statistically significant association of the presence of FAC and clinical improvement (p=.017) with an 85% positive predictive value.

ResultsResults

ConclusionsConclusions

Patients who are "FAC+" are more likely to demonstrate clinical improvement following microdiscectomy.

The data suggest that the inflammatory milieu plays a significant role regarding improvement in patients undergoing discectomy for radiculopathy in lumbar HNP

The FAC represents a potential target for treatment in HNP.


Maybe…Maybe…

The results of the subset analysis suggest that patients with preoperative weakness have a very strong association The results of the subset analysis suggest that patients with preoperative weakness have a very strong association between presence of FAC and clinical improvement. between presence of FAC and clinical improvement.

This is an intriguing finding that the removal of the inflammatory component may be more related to outcomes, This is an intriguing finding that the removal of the inflammatory component may be more related to outcomes, not necessarily the mechanical compression. (Chemical Radiculitis)not necessarily the mechanical compression. (Chemical Radiculitis)


For Spine specialists it maybe the reason For Spine specialists it maybe the reason why patients don’t respond to injections. why patients don’t respond to injections.


Do we do assays on all patients for presence of FAC?Do we do assays on all patients for presence of FAC?

The relative contribution of inflammatory processes versus mechanical The relative contribution of inflammatory processes versus mechanical processes is evolvingprocesses is evolving

Outcomes of Fluoroscopically Guided Outcomes of Fluoroscopically Guided Lumbar Transforaminal Epidural Lumbar Transforaminal Epidural Steroid Injections in Degenerative Steroid Injections in Degenerative Lumbar Spondylolisthesis Patients Lumbar Spondylolisthesis Patients

Study # 5Study # 5

•Outcomes of Fluoroscopically Guided Lumbar Transforaminal Epidural Steroid Injections in Degenerative Lumbar Spondylolisthesis Patients

• Kraiwattanapong, C

• Asian Spine J 2014;8(2):119-128 • http://dx.doi.org/10.4184/asj.2014.8.2.119 .


• Fluoroscopically guided TFESI is frequently being used for treatment of radicular pains in lumbar disc herniation, spinal stenosis and degenerative disc disease patients with various results.

• There has been no study which has exclusively evaluated the effectiveness of epidural steroid injections in patients with Degenerative Lumbar Spondylolisthesis (DLS).

PurposePurpose

• Report the short- and long-term outcomes of fluoroscopically guided lumbar TFESI in DLS patients.

MethodsMethods

38 DLS patients who underwent 38 DLS patients who underwent fluoroscopically guided lumbar TFESI during fluoroscopically guided lumbar TFESI during April 2009 to March 2010 April 2009 to March 2010

MethodsMethods

22 gauge spinal needles at spondylolisthesis level22 gauge spinal needles at spondylolisthesis level

1% lidocaine 2mls1% lidocaine 2mls

Depomedrol 80mgDepomedrol 80mg

MethodsMethods

Inclusion criteria Inclusion criteria

1)1)Patients with history of low back pain and unilateral radiating pain at least below the knee joint Patients with history of low back pain and unilateral radiating pain at least below the knee joint

2)2)Patients with slip grade 1 degenerative lumbar spondylolisthesis, visible on plain radiographs and one or two levels of neural compression found Patients with slip grade 1 degenerative lumbar spondylolisthesis, visible on plain radiographs and one or two levels of neural compression found from the magnetic resonance imaging (MRI)from the magnetic resonance imaging (MRI)

3)3)Failures of conservative treatment by physiatrists for at least 6 weeks. Failures of conservative treatment by physiatrists for at least 6 weeks.

MethodsMethods

The patients were evaluated by an independent observer before the initial injection (pre-injection)The patients were evaluated by an independent observer before the initial injection (pre-injection)

2 weeks, 6 weeks, 3 months, 12 months 2 weeks, 6 weeks, 3 months, 12 months

Visual analog scale (VAS)Visual analog scale (VAS)Roland 5-point pain scaleRoland 5-point pain scaleStanding tolerance,Standing tolerance,Walking tolerance Walking tolerance Patient satisfaction scalePatient satisfaction scale

MethodsMethods

ResultsResults

ResultsResults

ResultsResults

ResultsResults


TFESI significantly reduced VAS and Roland 5-point pain scores for both short term and long term follow ups.TFESI significantly reduced VAS and Roland 5-point pain scores for both short term and long term follow ups.

Standing tolerance and walking tolerance only significantly improved in the short term (for 2 weeks), but in the Standing tolerance and walking tolerance only significantly improved in the short term (for 2 weeks), but in the long term there was no significant difference. long term there was no significant difference.

The patient satisfaction scale for this procedure was highest at 2 weeks and declined with time. The patient satisfaction scale for this procedure was highest at 2 weeks and declined with time.


All parameters indicated better outcome in one level of spinal stenosis patients than in two All parameters indicated better outcome in one level of spinal stenosis patients than in two levels of spinal stenosis patients. levels of spinal stenosis patients.

These findings may be explained by the poor neural structures and physiology caused by These findings may be explained by the poor neural structures and physiology caused by double compression sites in neural elements. double compression sites in neural elements.


The fluoroscopically guided lumbar TFESI is able to reduce VAS and Roland 5-point pain scale The fluoroscopically guided lumbar TFESI is able to reduce VAS and Roland 5-point pain scale and improves standing tolerance and walking tolerance in the short term for DLS patients. and improves standing tolerance and walking tolerance in the short term for DLS patients.

For long term results, it reduces VAS but the improvement in standing tolerance and walking For long term results, it reduces VAS but the improvement in standing tolerance and walking tolerance are limited. In addition, DLS patients with one level of spinal stenosis showed tolerance are limited. In addition, DLS patients with one level of spinal stenosis showed significantly better outcomes than DLS patients with two levels of spinal stenosis. significantly better outcomes than DLS patients with two levels of spinal stenosis.


Interesting…Interesting…

Not sure why ODI or SF36 was not used…Not sure why ODI or SF36 was not used…

Small sample sizeSmall sample size


Yes!Yes!

If spondylolisthesis chose TFESI or facets?If spondylolisthesis chose TFESI or facets?

Another option besides surgery.Another option besides surgery.


Reinforces the TFESI for Reinforces the TFESI for spondylolisthesisspondylolisthesis

Just Because We Have A Just Because We Have A Treatment…Treatment…

DoesnDoesn’’t Mean Use it!!!!t Mean Use it!!!!

David E. Fish, MD, MPH

Physical Medicine and Rehabilitation

Department of Orthopeadic Surgery

Documents

What will help my practice? David E. Fish, MD, MPH Professor, Department of Orthopaedics Physical Medicine and Rehabilitation, The UCLA Spine Center UCLA