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.

Related Content:

• Research – Lumbar Transforaminal Epidural Steroid Injections
• Which MRI Finding Predicts Benefit From Cervical Epidural Steroid Injections?
• Carpal Tunnel Syndrome – Electrodiagnostics
• Prepatellar Bursa Aspiration and Injection – Technique and Tips
• Distal Interphalangeal (DIP) Joint Injection – Technique and Tips

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

Related Content:

• Innervation of the Intervertebral Disc
• Abnormal MRI Lumbar Disc Pathology in Asymptomatic Individuals
• Multifidus Atrophy After Lumbar Radiofrequency Neurotomy
• Iliolumbar Syndrome
• VIDEOS: Lumbar Facet Injections under Fluoroscopy

By Chris Faubel, MD –

Spine. 1984 Sep;9(6):549-51.

A study of computer-assisted tomography. I. The incidence of positive CAT scans in an asymptomatic group of patients.

Wiesel SW, Tsourmas N, Feffer HL, Citrin CM, Patronas N.
http://www.ncbi.nlm.nih.gov/pubmed/6495024

Photo courtesy SpineUniverse.com

ABSTRACT

In order to study the type and number of CAT scan abnormalities of the lumbar spine that occur in asymptomatic people, 52 studies from a control population with no history of back trouble were mixed randomly with six scans from patients with surgically proven spinal disease, and all were interpreted by three neuroradiologists in a blinded fashion. Irrespective of age, 35.4% (26.6%, 51.0%, and 31.3%) were found to be abnormal. Spinal disease was identified in an average of 19.5% (23.8%, 22.7%, and 12.5%) of the under 40-year-olds, and it was a herniated nucleus pulposus in every instance. In the over 40-year-old age group, there was an average of 50% (29.2%, 81.5%, and 48.1%) abnormal findings, with diagnoses of herniated disc, facet degeneration, and stenosis occurring most frequently.
—————————————-

SUMMARY / MY THOUGHTS

I have already posted a collection of articles proving the high prevalence of lumbar pathology via MRI of asymptomatic patients, but what about CAT scans (computed tomography; CT scans)?

Continue Reading

Related Content:

• Prevalence of Cervical Spine MRI Pathology in Asymptomatic Individuals
• Is Asymptomatic Lumbar Spine Pathology Predictive of Future Low Back Pain?
• Abnormal MRI Lumbar Disc Pathology in Asymptomatic Individuals
• Learning to Read MRI of the Spine
• Understanding the MRI of Lumbar Degenerative Spondylolisthesis and Spinal Stenosis

By Chris Faubel, MD –

Source: chirogeek.com

J Bone Joint Surg Am. 2001 Sep;83-A(9):1306-11.

The value of magnetic resonance imaging of the lumbar spine to predict low-back pain in asymptomatic subjects : a seven-year follow-up study.

Borenstein DG, O’Mara JW Jr, Boden SD, Lauerman WC, Jacobson A, Platenberg C, Schellinger D, Wiesel SW.
Division of Rheumatology, George Washington University Medical Center, Washington, DC 20037, USA.
http://www.ncbi.nlm.nih.gov/pubmed/11568190

Photo courtesy ChiroGeek.com

Related Content:

• Prevalence of Cervical Spine MRI Pathology in Asymptomatic Individuals
• Prevalence of Lumbar Spine Pathology on CAT scans in Asymptomatic Individuals
• VIDEOS: Lumbar Facet Injections under Fluoroscopy
• Abnormal MRI Lumbar Disc Pathology in Asymptomatic Individuals
• Iliolumbar Syndrome

By Chris Faubel, MD –

Magnetic resonance imaging (MRI) of the lumbar spine has undoubtedly become a valuable tool in the assessment of patients with low back and radiating lower extremity pain.

But over the years, MR has become over-utilized.  Besides the excessive costs to the health care system, the findings obtained on MRI of the lumbar spine have led to a psychological stress on the patient.   The misinterpretation of results by physicians and mid-level providers not familiar with the prevalence of pathology in asymptomatic individuals, has become a problem.

An MR report showing disc degeneration of the L3/4, L4/5, and L5/S1 discs, minimal bulging of the L3/4 intervertebral disc, and mild facet hypertrophy of the L5/S1 facet on the right, somehow gets interpreted in the mind of the patient as, “my low back is falling apart and my discs are poking into the spine”.

Hopefully the below collection of article abstracts will solidify the evidence, and serve as a resource for physicians and other health care providers.

Continue Reading

Related Content:

• Prevalence of Cervical Spine MRI Pathology in Asymptomatic Individuals
• Innervation of the Intervertebral Disc
• Prevalence of Lumbar Spine Pathology on CAT scans in Asymptomatic Individuals
• Learning to Read MRI of the Spine
• Understanding the MRI of Lumbar Degenerative Spondylolisthesis and Spinal Stenosis

By Chris Faubel, MD –

eorthopod.com

PM&R. 2009 Aug;1(8):719-22.

The significance of multifidus atrophy after successful radiofrequency neurotomy for low back pain.

Dreyfuss P, Stout A, Aprill C, Pollei S, Johnson B, Bogduk N.
Department of Rehabilitation Medicine, University of Washington, 21108 NE 129th CT, Woodinville, WA 98077, USA. pauldreyfuss@gmail.com

http://www.ncbi.nlm.nih.gov/pubmed/19695523

**picture to the right courtesy of eorthopod.com

Continue Reading

Related Content:

• Innervation of Lumbar Facet Joints
• Intradiscal Pressures in Various Everyday Positions and Activities
• Iliolumbar Syndrome
• VIDEOS: Lumbar Facet Injections under Fluoroscopy
• Learning to Read MRI of the Spine

Related Content:

• VIDEOS: Lumbar Facet Injections under Fluoroscopy
• Innervation of Lumbar Facet Joints
• Painless Injections – Taking The Sting Out
• Lateral Epicondylitis
• Innervation of the Intervertebral Disc