Faculty Bibliography

Study Design/UNASSIGNED:Retrospective cohort study. Objective/UNASSIGNED:To investigate radiological differences in lumbar disc herniations (herniated nucleus pulposus [HNP]) between patients receiving microscopic lumbar discectomy (MLD) and nonoperative patients. Methods/UNASSIGNED:test and chi-square analyses compared differences in the groups, binary logistic regression analysis determined odds ratios (ORs), and decision tree analysis compared the cutoff values for risk factors. Results/UNASSIGNED:< .01). Conclusion/UNASSIGNED:Patients who underwent MLD treatment had significantly different axial HNP area, frequency of caudal migration, magnitude of cephalad/caudal migration, and disc herniation MRI signal compared to patients with nonoperative treatment.

BACKGROUND: There is uncertainty in the literature over the relative effectiveness of lumbar epidural interlaminar (IL) steroid injection versus transforaminal (TF) steroid injection for lumbar radiculopathy. Most studies to date have been retrospective, or technically focused. OBJECTIVE: To complete a randomized, blinded, prospective outcome study of the short-term benefit for IL versus TF epidural steroids for the treatment of subacute lumbar radicular pain. STUDY DESIGN: Prospective, randomized, blinded, subacute efficacy trial. SETTING: Tertiary care pain management center, major metropolitan city, United States METHODS: After institutional review board approval, 42 age-matched patients with similar lower back pain and unilateral radicular symptoms were enrolled and randomized in a patient and evaluating physician blinded trial to IL or TF epidural steroids from 2007 through 2009. Prior to intervention and 10-16 days after injection, each participant was evaluated by questionnaire and physical exam by an independent physician. All injections were performed by the same physician. Thirty-eight participants completed the study, 18 in the IL group and 20 in the TF group. Four participants required a repeat injection, and 2 participants crossed over to the alternative injection type (IL to TF). RESULTS: Overall, physical exam, diagnostic testing, disability, activity, depression measures, and opioid pill use were similar between the 2 groups, both pre-injection baseline and post-injection improvement. In primary outcomes, the post-injection follow-up Numeric Rating Scale (NRS) was more greatly reduced in the TF group. The NRS decreased from 7.0 +/- 1.9 to 3.9 +/- 3.1 (mean values +/- standard deviation) in the IL group and 6.4 +/- 2.1 to 1.7 +/- 1.4 in the TF group. The Oswestry Disability Index was reduced from 37.5 +/- 12.6 to 19.0 +/- 16.7 in the IL group and 38.3 +/- 6.4 to 21.6 +/- 16.8 in the TF group. In secondary outcomes, the depression scale was reduced from 4.39 +/- 3.22 to 2.28 +/- 3.20 in the IL group and 4.10 +/- 1.94 to 1.65 +/- 1.63 in the TF group. Walking tolerance was increased from 8.1 +/- 4.6 blocks to 10.6 +/- 4.4 in the IL group and 8.9 +/- 5.3 blocks to 11.8 +/- 4.2 in the TF group. LIMITATIONS: The study did not examine long-term outcomes. A single experienced interventionalist performed all injections. CONCLUSION: Results suggest that patients may experience greater subjective relief, at least initially, from TF epidural steroid injections over IL. However, more objective, and likely subacute, therapeutic effects are similar

This article is the second article in a two-part review on lumbar facet joint pathology. In this review, we discuss the current concepts and controversies regarding the proper diagnosis and management of patients presenting with presumed facet-mediated lower back pain. All efforts were made to include the most relevant literature from the fields of radiology, orthopaedics, physiatry, and pain management. Our focus in this article is on presenting the evidence supporting or refuting the most commonly employed injection-based therapies for facet-mediated lower back pain

We present a two-part review article on the current state of knowledge of lumbar facet joint pathology. This first article discusses the functional anatomy, biomechanics, and radiological grading systems currently in use in clinical practice and academic medicine. Facet joint degeneration is presented within the larger context of degenerative disc disease to enable the reader to better understand the anatomical changes underlying facet-mediated lower back pain. Other less-common, but equally important etiologies of lumbar facet joint degeneration are reviewed. The existing grading systems are discussed with specific reference to the reliability of CT and MR imaging in the diagnosis of lumbar facet osteoarthritis. It is hoped that this discussion will stimulate debate on how best to improve the diagnostic reliability of these tests so as to improve both operative and non-operative treatment outcomes

Argument in the literature exists over lumbar epidural interlaminar steroid injection (LESI) verses transforminal (TF) technique as the most effective therapy in lumbar radiculopathy. However, all studies to date have been retrospective. After IRB approval, 42 age matched patients with similar lower back pain and unilateral radicular symptoms were enrolled and randomized in a double blind trial to LESI or TF from 2007 to 2009. Prior to intervention and 10-16 days after injection, each patient was evaluated by patient questionnaire and physical exam by an independent physician. 38 patients completed the study, 18 in the LESI and 20 in the TF group. In both groups, 2 patients required repeat injection, and 1 patient crossed over to the alternative injection type. Overall, physical exam, diagnostic testing, disability, activity and depression measures, and opioid pill use, were similar between the 2 groups, both pre-injection baseline and post-injection improvement. The Oswestry Disability Index (ODI%) was reduced from 37.5+/-12.6 (mean values +/- standard deviation) to 19.0+/-16.7 (49.3%+/-39.2%) in the LESI group and 38.3+/-6.4 to 21.6+/-16.8 (43.7%+/-34.8%) in the TF group. Depression scale was reduced from 4.39+/-3.22 to 2.28+/-3.20 (48.1%+/-52.0%) in the LESI group and 4.10+/-1.94 to 1.65+/-1.63 (61.0%+/-39.1) in the TF group. Walking tolerance was increased from 8.1+/-4.6 blocks to 10.6+/-4.4 (30.8%+/-133.2%) in the LESI group and 8.9+/-5.3 blocks to 11.8+/-4.2 (32.8%+/-318.7%) in the TF group. The follow-up patient numerical rating scale (NRS) was more greatly reduced in the TF group. NRS decreased from 7.0+/-1.9 to 3.9+/-3.1 (44.4%+/-37.6) in the LESI group and 6.4+/-2.1 to 1.7+/-1.4 in the TF group (73.2%+/-21.3%). Overall, results suggest that patients may experience greater subjective relief, as least initially, from TF epidural steroid injections over LESI. However, more objective, and likely subacute, therapeutic effects are similar

Clinical decision making for injured boxers follows the same therapeutic principles as the treatment plan for other injured athletes. Just as surgical techniques have improved, so has the scientific basis for implementing therapeutic exercises progressed to return the athletes to their former level of competition