The Pain Source

By Chris Faubel, MD –

Patients undergoing transforaminal epidural steroid injections show greater functional improvement if they have positive EMG findings of lumbar radiculopathy.

J Pain. 2008 Jan;9(1):64-70.

Right L4 Transforaminal Epidural Steroid Injection

The use of electromyography to predict functional outcome following transforaminal epidural spinal injections for lumbar radiculopathy.
Fish DE, Shirazi EP, Pham Q.
Department of Orthopedics, UCLA School of Medicine, Los Angeles, California 90404
Get the abstract here

Summary of Study

• Purpose: to determine if objective EMG findings can predict functional benefit after a lumbar transforaminal epidural steroid injection
• Retrospective chart review
• Study Participants
  • Patients who presented to the Veterans Affairs (VA) hospital in Los Angeles between July 1, 2000, and June 30, 2002.
  • Pain level and functional status (using the Oswestry Disability Index – ODI) was filled out before the injection, and at a follow-up visit (and these were kept electronically).
  • Inclusion criteria
    • EMG completion before the procedure with a diagnosis of an L5 or S1 radiculopathy
    • Transforaminal epidural steroid injection (TF-ESI) performed at L4 and/or L5
    • Symptomatic pain in only one extremity
    • Completion of self-assessment surveys before the interventional spine procedure and at follow-up
  • To be considered “EMG-positive”
    • Evidence of denervation or reinnervation on needle EMG
    • Two muscles innervated by 2 nerves from the same spinal cord level needed to be positive .
  • Baseline characteristics
    • Number of patients = 39
    • Age = 60 (mean; ± 12.5 years)
• Methods
  • The level of injection was based on the EMG findings, physical examination, magnetic resonance imaging (MRI), and clinical symptoms.
  • No patient received more than two levels of injections.
  • Injectate used
    • 40-mg triamcinolone acetonide (Kenalog) + an unknown amount of 1% lidocaine
    • If two levels were injected, the injectate was divided equally between the two levels.
• Results
  • The pre-injection ODI (Oswestry Disability Index) scores were essentially equal.
  • The pre-injection pain scores on the VAS were similar as well.
  • Two groups
    • EMG-positive patients
      • 18 patients
      • Post-injection ODI improvement = 7.11
    • EMG-negative/normal patients
      • 21 patients
      • Post-injection ODI improvement = 3.2
  • The post-injection VAS scores were improved after the injection, but the difference between the  groups was not statistically different.
• Limitations of the study
  • No evaluation of medications taken or changed during the pre- and post-injection ODI
  • No comparison of prior surgical interventions to the lumbar spine
  • No standardized time between symptom onset and EMG testing
  • Not a heterogenous group of patients
  • The injectionists were not blinded to the EMG results

• Conclusion
  • Patients undergoing transforaminal epidural steroid injections show greater functional improvement if they have positive EMG findings of lumbar radiculopathy.
  • Analog pain scores do not help in the decision-making of treatment options for patients with lumbar radiculopathy.
  • This study shows the diagnostic value of needle EMG in the prognostic success of patients prior to lumbar TF-ESIs, while simple pain scores are of little value.

Future Research

• Evaluate the psychological and medication factors that may determine a patient’s relief from lumbar epidural steroid injections.
• Also look at interlaminar vs transforaminal ESI relief in EMG-positive vs EMG-negative patients.

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• Research – Lumbar Transforaminal Epidural Steroid Injections
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• Distal Interphalangeal (DIP) Joint Injection – Technique and Tips

By Chris Faubel, MD –

Image courtesy Dr. Hazem Eissa

Am J Phys Med Rehabil. 2009 Mar;88(3):239-46
MRI prediction of therapeutic response to epidural steroid injection in patients with cervical radiculopathy.
Fish DE, Kobayashi HW, Chang TL, Pham Q.Department of Orthopaedics, Physical Medicine and Rehabilitation, David Geffen School of Medicine at UCLA, Los Angeles, California, USA.
Get the abstract here

Summary of Study

-

• Purpose: to find out if particular MRI finding can predict therapeutic success from cervical interlaminar epidural steroid injections (C-ILESIs) in patients with cervical radiculopathy
• Continue Reading

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• Complications of Cervical Transforaminal Epidural Steroid Injections
• Research – General Epidural Steroid Injections
• Videos: Cervical Interlaminar ESI
• Are EMG Findings Related to Epidural Steroid Injection Relief?
• Carpal Tunnel Syndrome: A Review

By Chris Faubel, MD –

Image by © Laura Doss/Corbis

N Engl J Med. 2010 Aug 19;363(8):743-54
A randomized trial of tai chi for fibromyalgia.
Wang C, Schmid CH, Rones R, Kalish R, Yinh J, Goldenberg DL, Lee Y, McAlindon T.
Division of Rheumatology, Tufts Medical Center, Tufts University School of Medicine, Boston, MA 02111, USA. cwang2@tuftsmedicalcenter.org
Get the abstract here

Summary of Study

• Purpose: to evaluate the effectiveness of Tai Chi in the multidisciplinary treatment of patients with fibromyalgia.
• Single-blind, randomized, controlled trial
• Study Participants
  • 21 years of age or older and fulfilled the American College of Rheumatology 1990 diagnostic criteria for fibromyalgia.
  • Exclusion criteria:
    • Done Tai Chi in the prior 6 months
    • Other diagnosed medical conditions known to contribute to fibromyalgia symptoms
  • Were able to continuing using their same medications and to maintain their usual physician visits (changes in meds were allowed)
  • 59 total subjects (after screenings): 30 in the Tai Chi group; 29 in the control group
  • Baseline characteristics (means)
    • Female: 86%
    • Whites: 56%
    • Age of 50
    • BMI of 32.7
    • Duration of fibromyalgia symptoms = 11 years
• Methods
  • Tai Chi intervention (classic Yang-style) — taught by tai chi master
    • Twice a week for 12 weeks
    • 60 minutes per session
    • Subjects were told to practice tai chi at home for at least 20 minutes each day.
    • At the end of the 12 weeks, they were encouraged to maintain their tai chi, using an instructional DVD, up until the follow-up visit at 24 weeks.
  • Control intervention (wellness education and stretching program)
    • Twice a week for 12 weeks
    • 60 minutes per session
      • 40-minute didactic lesson on a topic relating to fibromyalgia (diagnostic criteria; coping strategies and problem-solving techniques; diet and nutrition; sleep disorders and fibromyalgia; pain management, therapies, and medications; physical and mental health; exercise; and wellness and lifestyle management)
      • 20 minutes of stretching (upper body, trunk, and lower body; held for 15 to 20 seconds)
    • Told to practice stretching at home for 20 minutes a day
• Outcome Measures
  • Fibromyalgia impact questionnaire (FIQ)
    • Measure of the overall severity of fibromyalgia as rated by patients.
    • Scores range from 0-100.  Higher scores = more severe
  • Visual analogue scale (VAS)
    • 0-10 scale.  Higher numbers = more pain
  • 6-minute walk test — by blinded staff
    • The distance covered.  Objective assessment of mobility.
  • Pittsburgh Sleep Quality Index (PSQI)
    • Scores range from 0 to 21.  Higher scores = worse sleep quality
  • Short-Form Health Survey (SF-36) – Physical and mental quality-of-life components
    • Higher scores = better health status
  • Center for Epidemiologic Studies Depression (CES-D)
    • Scores range from 0 to 60.  Higher scores = more severe depression
  • Recorded changes in the use of medications

• Results
  • Rate of attendance during the 12-week intervention
    • 77% for the tai chi group
    • 70% for the control group
  • No adverse events were noted
  • Tai chi group (30 subjects) vs. Control group (29 subjects) — MEAN CHANGES
    • FIQ
      • 12 weeks:  -27.8  vs  −9.4
      • 24 weeks:  −28.6  vs  -10.2
    • VAS
      • 12 weeks:  -2.5  vs  −0.6
      • 24 weeks:  −2.4  vs  -−0.7
    • PSQI
      • 12 weeks:  -3.6  vs  -0.7
      • 24 weeks:  −4.2  vs  -1.2
    • 6-minute walk test (yards)
      • 12 weeks:  +60.6  vs  +16.3
      • 24 weeks:  +49.8  vs  +23.2
    • BMI
      • No significant change in either group
    • SF-36 (physical component)
      • 12 weeks:  +8.5  vs  +1.4
      • 24 weeks:  +8.4  vs  +1.5
    • SF-36 (mental component)
      • 12 weeks:  +7.7  vs  +1.6
      • 24 weeks:  +8.5  vs  +1.2
    • CES-D
      • 12 weeks:  −8.1  vs  -2.3
      • 24 weeks:  −6.5  vs  -2.4

    Note: all of the above differences were statistically significant

    • The observed benefits exceeded the specified thresholds for clinically significant improvement in the FIQ score and in the measures used to assess pain, sleep quality, depression,  and quality of life, and these benefits were sustained at 24 weeks.
    • At 12 weeks, more subjects had discontinued medication used to treat fibromyalgia in the tai chi group than in the control group, but the difference was not statistically significant (11 of 31 patients vs. 4 of 26, P = 0.09).
• Conclusions
  • Tai chi is a safe and effective treatment in the multidisciplinary management of fibromyalgia.

Related Content:

• No Related Posts

By Chris Faubel, MD –

Source: The Journal of Bone and Joint Surgery. This is a 34 year old asymptomatic woman. Note the disc herniation contacting the cord between the 4th and 5th vertebrae

The Journal of Bone and Joint Surgery. 1990;72:1178-1184
Abnormal magnetic-resonance scans of the cervical spine in asymptomatic subjects. A prospective investigation
SD Boden, PR McCowin, DO Davis, TS Dina, AS Mark and S Wiesel
Department of Orthopaedic Surgery, George Washington University Medical Center, Washington, D.C. 20037
Get the abstract here

Summary of Study

• Purpose: to document the prevalence of cervical spine MRI pathology in asymptomatic individuals (false positives)
• Prospective study
• Sixty-three (63) asymptomatic volunteers (20-73 years old)
  • Subjects had to have no history of cervical pain or trauma, pain in the shoulder, or radicular symptoms referable to the cervical nerve-roots.
• Continue Reading

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• Learning to Read MRI of the Spine
• Understanding the MRI of Cervical Nerve Compression

By Chris Faubel, MD –

Source: eOrthopod.com

PM R. 2010 Sept;2:817-821
Accuracy of Ultrasound-Guided Versus Palpation-Guided Acromioclavicular Joint Injections: A Cadaveric Study
Peck E, Lai JK, Pawlina W, Smith J.
Physical Medicine and Rehabilitation, Mayo Clinic College of Medicine, Mayo Clinic Sports Medicine Center, 200 First St SW, Rochester, MN 55905(1).
Get the abstract here

Summary of study:

• Prospective study
• 20 adult (50+ years old) unembalmed cadaveric acromioclavicular joint (ACJ) specimens (10 left and 10 right) — specimens at room temperature
• Continue Reading

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By Chris Faubel, MD –

Source: Mayo Foundation for Medical Education and Research

J Bone Joint Surg Am. 2008 Sep;90(9):1932-8.
Perils of intravascular methylprednisolone injection into the vertebral artery. An animal study.
Okubadejo GO, Talcott MR, Schmidt RE, Sharma A, Patel AA, Mackey RB, Guarino AH, Moran CJ, Riew KD.
Department of Orthopaedic Surgery, Washington University School of Medicine, St. Louis, Missouri, USA. gokubadejo@hotmail.com
Get the abstract here

Summary of Study

• Purpose: to investigate whether use of particulate steroids carried with it, a greater risk of neurologic damage from cervical transforaminal epidural steroid injections
  
• Prospective, exploratory pilot study
• Animal study – eleven (11) adult, male pigs weighing between 110 and 136 pounds (50-62 kg)
  
• Continue Reading

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• Radiopaque Contrast Use In Pain Medicine

By Chris Faubel, MD –

Image from MendMeShop.com

PM R. 2010 Aug;2(8):732-739. Epub 2010 Jul 3.
Accuracy of Ultrasound-Guided versus Unguided Pes Anserinus Bursa Injections.
Finnoff JT, Nutz DJ, Henning PT, Hollman JH, Smith J.
Physical Medicine and Rehabilitation, Mayo Clinic College of Medicine, Mayo Clinic Sports Medicine Center, 200 First St SW, Rochester, MN 55905(1).
Get the abstract here

Summary of study:

• Single-blinded, prospective study — physicians obviously knew if they were using ultrasound or not
• 24 adult cadaveric lower extremity specimens were used
• Continue Reading

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Posted by Azlan Tariq, D.O.

Diagnosis of Sacroiliac Joint Pain: Validity of individual provocation tests and composites of tests

Manual Therapy 10 (2005) 207–218

Mark Lasletta, Charles N. Aprill, Barry McDonald, Sharon B. Young, Department of Health and Society, Linko¨pings Universitet, Linko¨ping, Sweden, Magnolia Diagnostics, New Orleans, LA, USA,  Massey University, Institute of Information and Mathematical Sciences, Albany, New Zealand, Mobile Spine and Rehabilitation Center, Mobile, AL, USA

http://www.ncbi.nlm.nih.gov/pubmed/16038856

ABSTRACT

Objective: Previous research indicates that physical examination cannot diagnose sacroiliac joint (SIJ) pathology. This study examined the diagnostic power of pain provocation SIJ tests singly and in various combinations, in relation to an accepted criterion standard.

Continue Reading

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• VIDEOS: Lumbar Facet Injections under Fluoroscopy
• VIDEO: Subacromial Bursa Injection under fluoroscopy
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• Full Can Test
• Empty Can Test

Posted by Azlan Tariq, D.O.

New In Vivo Measurements of Pressures in the Intervertebral Disc in Daily Life

SPINE Volume 24, Number 8, pp 755–762
Hans–Joachim Wilke, PhD, Peter Neef, MD, Marco Caimi, MD, Thomas Hoogland, MD, and Lutz E. Claes, PhD
Department of Orthopedic Research and Biomechanics, Ulm, Germany
Department of Physical therapy and Rehabilitation, Basel, Switzerland

http://www.ncbi.nlm.nih.gov/pubmed/10222525

ABSTRACT

Objective: The goal of this study was to measure intradiscal pressure to complement earlier data from Nachemson with dynamic and long-term measurements over a broad range of activities. Continue Reading

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• Innervation of the Intervertebral Disc
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• Multifidus Atrophy After Lumbar Radiofrequency Neurotomy
• Iliolumbar Syndrome
• VIDEOS: Lumbar Facet Injections under Fluoroscopy

By Chris Faubel, MD

J Rheumatol. 2004 Nov;31(11):2265-8.

Corticosteroid Hip Injection under Fluoroscopy - courtesy Hazem Eissa, M.D., Pain management at Ochsner medical center, Associate professor LSU & Tulane

Intraarticular corticosteroid injection: pain relief in osteoarthritis of the hip?

Kullenberg B, Runesson R, Tuvhag R, Olsson C, Resch S.

Department of Orthopedics, Blekinge Hospital, Karlshamn, Sweden. bjorn.kullenberg@lthlekinge.se

http://www.ncbi.nlm.nih.gov/pubmed

ABSTRACT

OBJECTIVE: Osteoarthritis (OA) is one of the most common causes of morbidity in the elderly population, and surgery is often preceded by years of pain and disability. Intraarticular corticosteroid injections in osteoarthritic joints may play a role in the therapeutic plan and can afford quick pain relief but do not alter the underlying disease. There is a paucity of well controlled studies that provide recommendations for the use of corticosteroids in OA of the hip.

Continue Reading

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• Pes Anserine Bursa Injection – Technique and Tips