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Vertebral body fracture is the most common complication of osteoporosis. A thorough evaluation is needed to determine the patient's predisposition to fracture. Underlying disease states also should be addressed. Plain radiography is the standard imaging modality for spinal fractures; MRI also provides important information. Conservative treatment measures (eg, relative rest, narcotic analgesics, spinal orthoses, and extension-biased activities) are often used for pain relief, minimizing the sequelae of deconditioning, and maximizing function. Two minimally invasive percutaneous procedures, vertebroplasty and kyphoplasty, are available. Early vertebroplasty has been effective in pain relief and in precluding the adverse effects of deconditioning. Kyphoplasty has a presumed advantage of better restoration of vertebral body height and less risk of cement extravasation. [ABSTRACT FROM AUTHOR]

A 40-yr-old woman received a series of three interlaminar epidural steroid injections for the treatment of axial neck pain secondary to degenerative disc disease. Immediately after her third injection, she experienced symptoms of a dural puncture-induced headache. This headache persisted on a daily basis for 3 mos, despite two epidural blood patches using an interlaminar approach, which was finally completely abated with a transforaminal blood patch. The headache was immediately relieved and remained alleviated through the follow-up interval of 1 yr. In this patient, a fluoroscopically guided transforaminal epidural blood patch proved to be more effective than the classic blind interlaminar approach in the treatment of post-dural puncture headache. [ABSTRACT FROM AUTHOR]

Objective. To determine the inciting events leading to the development of sacroiliac joint syndrome (SIJS).Methods. This was a retrospective descriptive cohort series from an academic interdisciplinary spine center. Consecutive patients presenting with low back or buttock pain with or without leg symptoms who met specific inclusion and exclusion criteria for the diagnosis of SIJS were included in the study. Inciting events leading to the development of SIJS in these patients were categorized into traumatic, cumulative, and idiopathic events.Results. Of 194 patients who were included in the study, 54 patients had symptom resolution with one or more therapeutic intraarticular sacroiliac joint injections, following a positive diagnostic injection. Those patients were given the diagnosis of SIJS. Of these, 24 (44%) had had a traumatic event (13 motor vehicle accidents, six falls onto the buttock, three immediately postpartum, one severe football tackle, and one pelvis fracture). Eleven (21%) patients were considered to have a cumulative injury (four lifting, two running, three altered gait due to lower extremity disorder, one crew training injury, and one forceful hip extension injury). Nineteen (35%) patients had spontaneous or idiopathic onset of sacroiliac joint pain.Conclusion. SIJS can occur following a traumatic event or cumulative shear events, or can occur spontaneously. [ABSTRACT FROM AUTHOR]

We report a collegiate field hockey player who sustained a sacral fatigue-type stress fracture that manifested as persistent low back and leg pain. The diagnosis of sacral stress fracture was suggested by history and physical examination and confirmed by magnetic resonance imaging. Our patient experienced complete resolution of symptoms after a 3-mo interval of activity restriction. This article describes the first reported case of a sacral stress fracture in a field hockey player. [ABSTRACT FROM AUTHOR]

Objective: To evaluate the predictive utility of the pattern of low back pain (LBP) in detecting the source of LBP as internal disk disruption (IDD), facet joint pain (FJP), or sacroiliac joint pain (SIJP)., Design: Retrospective chart review., Setting: University spine center., Patient Sample: A total of 170 cases from 156 patients presenting with LBP whose low back disorder was definitively diagnosed. The mean age was 54.4 years (SD, 16.2) and median duration of LBP was 12 months (interquartile ranges, 6-32)., Methods: Charts of consecutive LBP patients who underwent definitive diagnostic spinal procedures including provocation diskography, facet joint blocks, and sacroiliac joint blocks were retrospectively reviewed. Each patient with LBP was queried as to the exact location of their LBP: midline, defined as in-line with the spinous processes, and/or paramidline, defined as lateral to 1 fingerbreadth adjacent to the midline., Outcome Measures: In patients with a definitive diagnosis for the source of LBP, the proportion of each diagnosed source of pain was calculated. χ(2) tests were used to identify differences in the percentages of midline and paramidline LBP among the groups of patients testing positive for IDD, FJP, or SIJP. Diagnostic measures of sensitivity, specificity, positive and negative predictive values, diagnostic accuracy, and likelihood ratios of positive and negative tests using the presence/absence of midline and paramidline pain for the diagnosis of IDD, FJP, and SIJP were estimated., Results: With cases of IDD, significantly greater percentages of patients reported midline LBP (95.8%; χ(2) = 101.4, df = 2, P < .0001) as compared with cases of FJP (15.4%) or SIJP (12.9%). In cases of IDD, significantly lower percentages of patients reported paramidline pain (67.3%; χ(2) = 16.1, df = 2, P = .0003) as compared with cases of FJP (95.0%) or SIJ (96.0%). In cases of IDD, significantly greater percentages of patients reported midline LBP (95.8%; χ(2) = 101.4, df = 2, P < .0001) as compared with cases of FJP (15.4%) or SIJP (12.9%). The specificity of midline LBP for IDD, FJP, and SIJP was 74.8% (95% CI = 65.0%-82.9%), 28.0% (20.1%-37.0%), and 36.0% (28.0%-44.5%), respectively. The negative predictive value of paramidline LBP for IDD, FJP, and SIJP was 29.2% (95% CI = 12.6%-51.1%), 91.7% (73.0%-99.0%), and 95.8% (78.9%-99.9%). The diagnostic accuracy of midline LBP for IDD, FJP, and SIJP was 83.5%, 24.1%, and 31.8%, respectively., Conclusions: The presence of midline LBP increases the probability of lumbar IDD and reduces the probability of symptomatic FJ and SIJ dysfunction. The presence of isolated paramidline LBP increases the probability of symptomatic FJ or SIJ but mildly reduces the likelihood of lumbar IDD., (Copyright © 2011 American Academy of Physical Medicine and Rehabilitation. Published by Elsevier Inc. All rights reserved.)

The management of chronic low back pain (CLBP) has proven very challenging in North America, as evidenced by its mounting socioeconomic burden. Choosing amongst available nonsurgical therapies can be overwhelming for many stakeholders, including patients, health providers, policy makers, and third-party payers. Although all parties share a common goal and wish to use limited health-care resources to support interventions most likely to result in clinically meaningful improvements, there is often uncertainty about the most appropriate intervention for a particular patient. To help understand and evaluate the various commonly used nonsurgical approaches to chronic low back pain, the North American Spine Society has sponsored this special focus issue of The Spine Journal, titled Evidence-Informed Management of Chronic Low Back Pain Without Surgery. Articles in this special focus issue were contributed by leading spine practitioners and researchers, who were invited to summarize the best available evidence for a particular intervention and encouraged to make this information accessible to nonexperts. Each of the articles contains five sections (description, theory, evidence of efficacy, harms, and summary) with common subheadings to facilitate comparison across the 24 different interventions profiled in this special focus issue, blending narrative and systematic review methodology as deemed appropriate by the authors. It is hoped that articles in this special focus issue will be informative and aid in decision making for the many stakeholders evaluating nonsurgical interventions for CLBP.

Sacral stress fractures are a relatively common occurrence and can be a debilitating source of low back pain. They generally occur in two distinctly different patient populations, and are of two different etiologies. Sacral insufficiency-type fractures are seen in elderly osteoporotic persons, and fatigue fractures are seen young active individuals. Although the clinical presentation of these fractures is similar, medical rehabilitation and interventional spine management strategies differ according to etiology. Although conservative management strategies have resulted in good outcomes, other treatment options have recently developed. This article provides an overview of the clinical presentation, pathology, and treatment options for sacral stress fractures and discusses some of the recent literature surrounding this interesting topic.

Objective: To report the short-term side effects and complications after percutaneous disc decompression utilizing coblation technology., Design: Following institutional review board approval, consecutive patients who were to undergo percutaneous disc decompression using coblation technology (nucleoplasty) were prospectively enrolled. Patients were questioned preoperatively, postoperatively, and 24 hrs, 72 hrs, 1 wk, and 2 wks postprocedure by an independent reviewer regarding 17 possible symptom complications, which included bowel or bladder symptoms, muscle spasm, new pain, numbness/tingling or weakness, fevers/chills, rash/pruritus, headaches, nausea/vomiting, bleeding, and needle insertion site soreness. Statistical analysis was performed using Wilcoxon's signed-rank test., Results: A total of 53 patients enrolled, of whom four patients dropped out. Two patients had increased symptoms and opted for surgery. Two patients could not be contacted. The most common side effects at 24 hrs postprocedure was soreness at the needle insertion site (76%), new numbness and tingling (26%), increased intensity of preprocedure back pain (15%), and new areas of back pain (15%). At 2 wks, no patient had soreness at the needle insertion site or new areas of back pain; however, new numbness and tingling was present in 15% of patients. Two patients (4%) had increased intensity of preprocedure back pain. There were statistically significant reductions in visual analog scale score for back pain and leg pain (P < 0.05)., Conclusions: Based on this preliminary data, nucleoplasty seems to be associated with short-term increased pain at the needle insertion site and increased preprocedure back pain and tingling numbness but without other side effects.

Objective: To critically review the best available trials of the utility of transforaminal epidural steroid injections (TFESIs) or selective nerve root blocks (SNRBs) to treat lumbosacral radiculopathy., Data Sources: MEDLINE (PubMed, Ovid, MDConsult), EMBASE, and the Cochrane database. Databases were searched from inception through 2003., Study Selection: A database search was conducted by using the following key words: prospective , transforaminal and foraminal epidural steroid injections , selective nerve root block and injection , and periradicular and nerve root injection . We included English-language, prospective, randomized studies of patients with lower-limb radicular symptoms treated with fluoroscopically guided nerve root or transforaminal epidural injections., Data Extraction: Data were compiled for each of the following categories: inclusion criteria, randomization protocol, total number of subjects enrolled initially and at final analysis, statistical analysis utilized, documentation of technique, outcome measures, follow-up intervals and results (positive or negative), and reported complications. These data were abstracted by 1 reviewer and reviewed by a second. Study quality was assessed with the system developed by the Agency for Health Care and Policy Research., Data Synthesis: We selected 6 articles for review. Our analysis identified a single article as the highest quality study addressing the appropriate use of TFESIs or therapeutic SNRBs. Coupled with the evidence provided by 4 other articles (1 article was excluded because its patients were not truly randomized), our review of the evidence for TFESIs found level III (moderate) evidence in support of these minimally invasive and safe procedures in treating painful radicular symptoms. However, conclusive evidence (level I) is lacking., Conclusions: The evidence for TFESIs reveals level III (moderate) evidence in support of these minimally invasive and safe procedures in treating painful lumbar radicular symptoms. Current studies support use of TFESIs as a safe and minimally invasive adjunct treatment for lumbar radicular symptoms. However, more prospective, randomized, placebo-controlled studies using sham procedures are needed to provide conclusive evidence for the efficacy of TFESIs in treating lumbar radicular symptoms.

Background Context: In a small prospective study assessing 10 symptomatic and 10 asymptomatic subjects, Schellhas et al. compared cervical discography to magnetic resonance imaging. Within that study he reported on the distribution of pain for the C3-C4 to C6-C7 levels. Four years later, Grubb and Ellis reported retrospective data from his 12-year experience using cervical discography from C2-C3 to C7-T1 in 173 patients. To date, no large prospective study defining pain referral patterns for each cervical disc has been performed., Purpose: To conduct a prospective visual and statistical descriptive study of pain provocation of a cohort of subjects undergoing cervical discography., Study Design/setting: Prospective multicenter descriptive study., Methods: Pain referral maps were generated for each disc level from patients undergoing cervical discography with at least two levels assessed. If concordant pain was reproduced in a morphologically abnormal disc, the subject immediately completed a pain diagram. An independent observer interviewed the subject and recorded the location of provoked symptoms. Visual data were compiled using a body sector bit map, which consisted of 48 clinically relevant body regions. Visual maps with graduated color codes and frequencies of symptom location at each cervical disc level were generated., Results: A total of 101 symptom provocation maps were recorded during cervical discography on 41 subjects. There were 10 at C2-C3, 19 at C3-C4, 27 at C4-C5, 27 at C5-C6, 16 at C6-C7 and 2 at C7-T1. Predominantly unilateral symptoms were provoked just as often as bilateral symptoms. The C2-C3 disc referred pain to the neck, subocciput and face. The C3-C4 disc referred pain to the neck, subocciput, trapezius, anterior neck, face, shoulder, interscapular and limb. The C4-C5 disc referred pain to the neck, shoulder, interscapular, trapezius, extremity, face, chest and subocciput. The C5-C6 disc referred pain to the neck, trapezius, interscapular, suboccipital, anterior neck, chest and face. The C6-C7 disc referred pain to the neck, interscapular, trapezius, shoulder, extremity and subocciput. At C7-T1 we produced neck and interscapular pain. Visual maps with graduated color codes and frequencies of symptom location at each cervical disc level were generated., Conclusions: In conclusion, these results confirm the observations of prior investigators that cervical internal disc disruption can elicit axial and peripheral symptoms. The particular patterns of pain generation allow the discographer to preprocedurally anticipate disc levels to assess. With these data, the number of disc punctures that are required can be limited rather than routinely assessing all cervical discs.

Objective: To report on the incidence of dysphonia and/or associated throat symptoms after steroid injections in the axial skeleton., Design: A prospective cohort study., Setting: Academic spine center., Participants: Patients (N = 100) undergoing a diagnostic injection followed by a therapeutic injection in the axial skeleton., Interventions: Not applicable., Main Outcome Measure: Presence or absence of dysphonia and/or associated throat symptoms, as determined by completion of a predetermined 10-item questionnaire. This questionnaire was administered before participation in the study and at specific intervals after a diagnostic injection and, again, after a therapeutic spinal injection., Results: There was a 12% incidence of transient dysphonia and/or associated throat symptoms in this study population after a therapeutic injection., Conclusions: Throat symptoms are a potential, albeit transient side effect, after an epidural space corticosteroid injection. The mechanism through which dysphonia or other throat symptoms develop is unknown but appears to be mediated by a systemic steroid effect.

Objective: To determine the incidence of complications and side effects of cervical and lumbosacral selective nerve root injections (SNRIs)., Design: Prospective, nonrandomized controlled trial of consecutive patients with independent interviews for immediate, 1-week, and 3-month follow-ups., Setting: Tertiary, academic spine center., Participants: Of 160 patients eligible for SNRI, 151 underwent 306 SNRIs (study group). Sixty patients who had not undergone any intervention served as the control group., Interventions: Diagnostic and therapeutic fluoroscopically guided cervical and lumbosacral SNRIs. Lidocaine (Xylocaine) was used in the diagnostic injections and a mixture of lidocaine and betamethasone was used in the therapeutic injections., Main Outcome Measures: Complications and side effects experienced during the procedure were recorded by the interventionalist. Side effects and complications experienced immediately, 1 week, and 3 months after injection were determined through independent interviews using a questionnaire format. The control group was independently interviewed using the same questionnaire., Results: There were no major complications, such as death, paralysis, spinal nerve injury, infection, or allergic reaction, during the study. Ninety-one percent of subjects had no side effects during the procedure. A positive response on interview was reported by 39.4% of the study subjects immediately after the procedure. Lumbosacral SNRI side effects were as follows: increased pain at the injection site (17.1%); increased radicular pain (8.8%); lightheadedness (6.5%); increased spine pain (5.1%); nausea (3.7%); nonspecific headache (1.4%); and vomiting (0.5%). Immediate side effects from cervical SNRI were as follows: increased pain at injection site (22.7%); increased radicular pain (18.2%); lightheadedness (13.6%); increased spine pain (9.1%); nonspecific headache (4.5%); and nausea (3.4%). At the 1-week interview, comparison of the study and control groups showed statistical significance for the following: pain at injection site, cervical ( P =.001) and lumbar ( P =.005); nonspecific headache, cervical ( P =.019); and nonspinal headache, cervical ( P =.002). At 3 months, 2 subjects complained of increased neck pain and 1 reported heartburn and fluid retention. Two lumbar SNRI subjects were lost to follow-up., Conclusions: There were no major complications with cervical and lumbosacral SNRIs, although various minor side effects occurred.

We present a case of L2/3 interspinous bursitis treated with extraspinal injections. No previous investigations have used fluoroscopically guided spinal injections to confirm the clinical relevance of the MRI features of this type of bursae. Autopsy studies have revealed an increased incidence of interspinous lumbar bursal cavities with advancing age. Afflicted patients present with localised, midline lower lumbar pain exacerbated by extension. In young athletes these symptoms can mimic spondylolysis. MRI is useful in detecting soft-tissue injury of the posterior elements. Fluoroscopically guided diagnostic and therapeutic extraspinal injections can be used for confirmation and treatment of pain from such bursae.

Objective: To investigate the outcomes resulting from the use of fluoroscopically guided therapeutic selective nerve root block in the nonsurgical treatment of traumatically induced cervical spondylotic radicular pain., Design: Retrospective study with independent clinical review. A total of 15 patients who met specific physical examination or electrodiagnostic criteria and failed to improve clinically after at least 4 wks of physical therapy were included. Each patient demonstrated a positive response to a fluoroscopically guided cervical selective nerve root block. Therapeutic selective nerve root blocks were administered in conjunction with physical therapy. Outcome measures included visual analog scale pain scores, employment status, medication usage, and patient satisfaction., Results: Patients' symptom duration before diagnostic injection averaged 13.0 mos. An average of 3.7 therapeutic injections were administered. Follow-up data collection transpired at an average of 20.7 mos after discharge from treatment. An overall good or excellent outcome was observed in three patients (20.0%). Among those treated without surgery, a significant reduction (P = 0.0313) in pain score was observed at the time of follow-up. Six patients (40.0%) proceeded to surgery., Conclusions: These initial and preliminary findings do not support the use of therapeutic selective nerve root block in the treatment of this challenging patient population with traumatically induced spondylotic radicular pain.

Background Context: Lumbar zygapophysial joints are currently believed to be a cause of axial low back pain. Once this diagnosis is made, decisions about when to institute a particular intervention and which treatment to offer is regionally and specialty dependent., Purpose: To perform a critical review of prior published studies assessing the use of interventional treatment options for the treatment of lumbar zygapophysial joint syndrome., Study Design: Evidence-based medicine analysis of current literature., Methods: A database search of Medline (PubMed, Ovid and MDConsult), Embase and the Cochrane database was conducted. The keywords used were low back pain, lumbar zygapophysial joint, lumbar facet joint, radiofrequency denervation, medial branch block, and intraarticular injection. After identifying all relevant literature, each article was reviewed. Data from the following categories were compiled: inclusion criteria, randomization of subjects, total number of subjects involved at enrollment and at final analysis. statistical analysis used, intervention performed, outcome measures, follow-up intervals and results. Guidelines described by the Agency for Health Care Policy and Research were then applied to these data., Results: This review determined that the evidence for the treatment of lumbar zygapophysial joint syndrome with intraarticular injections should be rated as level III (moderate) to IV (limited) evidence, whereas that for radiofrequency denervation is at a level III., Conclusions: Current studies fail to give more than sparse evidence to support the use of interventional techniques in the treatment of lumbar zygapophysial joint-mediated low back pain. This review emphasizes the need for larger, prospective, randomized controlled trials with uniform inclusion and exclusion criteria, standardized treatment, uniform outcome measures and an adequate duration of follow-up period so that definitive recommendations for the treatment of lumbar zygapophysial joint-mediated pain can be made.

Background Context: Perineural cysts are commonly found in the sacral region and are incidently discovered on imaging studies performed for the evaluation of low back and/or leg pain., Purpose: To report on a patient presenting with abdominal pain secondary to a large sacral perineural cyst., Study Design/setting: Case report. METHODS/PATIENT SAMPLE: A 47-year-old woman was referred to a specialized multidisciplinary spine center with complaints of left lower quadrant abdominal pain and left leg pain. Of significant note was the presence of constipation and urinary frequency over the preceding 8 months. Physical examination was normal. Magnetic resonance imaging of the lumbosacral spine revealed large perineural cysts eroding the sacrum and extending to the pelvis. The presence of abdominal symptoms prompted a neurosurgical consultation. However, after considering the possible risks associated with the surgical procedure, the patient opted to follow the nonsurgical route., Result and Conclusions: Although commonly visualized, sacral perineural cysts are rarely symptomatic. When symptomatic, it may be secondary to its size and location. Presence of abdominal pain in a patient with back and/or leg pain should prompt the evaluation of the lumbosacral spine.

Objective: To report the incidence and epidemiologic formation of previously undetected primary and secondary spine tumors presenting as spinal and/or extremity pain to a physiatrist practicing in an academic or private practice multidisciplinary spine center., Design: Multicenter retrospective chart review., Setting: Three multidisciplinary spine settings (1 academic, 2 private)., Participants: Charts of patients from 33 academic and 18 private practice settings., Interventions: Not applicable., Main Outcome Measures: Epidemiologic data collected included incidence, age, gender, race, and duration of symptoms before initial presentation. Symptom presentation data collected included intensity of pain when supine, sitting, standing, or walking; character of the pain; pain intensity as measured on the visual analog scale (VAS); spontaneous versus traumatic etiology; unexplained weight loss; presence of night pain; and fever. In addition, the results of radiographic studies including plain films, imaging, bone scan, and magnetic resonance imaging were recorded. The type of neoplastic disease was also assessed, primary versus metastatic, as well as the metastatic source., Results: The incidence of spine tumors was.69% in academic multidisciplinary spine centers and.12% in private practice multidisciplinary spine centers. Patients with spinal pain because of neoplastic disease who presented to musculoskeletal physiatrists were an average age of 65.3 years and reported a relatively high likelihood of night pain, aching character of symptom manifestation, spontaneous onset of symptoms, history of cancer, standing and walking provoking symptoms, and unexplained weight loss. In addition, the pain intensity level ranged widely, with an average VAS score of 6.8., Conclusions: There are many similarities and differences in the clinical presentation of patients with spinal pain from spine tumors who present to musculoskeletal physiatrists practicing in multidisciplinary spine centers when compared with those presenting to a primary care setting.

Spinal fusion for degenerative disc disease has been associated with a variety of side effects, including increased morbidity, infection, failed back syndrome, pseudoarthrosis, and acceleration of degenerative changes in adjacent intervertebral discs and facet joints. Based on the experience of arthroplasty of hip and other joints, there has been an escalating in research emphasizing the design and development of an artificial disc prosthesis. However, these artificial discs have not been very successful when compared with hip or knee replacements. Based on clinical and anatomical data, multiple authors have postulated that the degenerative process of intervertebral disc evolves through three stages; dysfunction, instability and stabilization, with relatively distinct clinical and radiological findings. Even though magnetic resonance imaging is considered as the primary diagnostic tool for degenerative disease, it is unable to reliably ascertain which disc level is responsible for generating axial pain symptoms. Consequently, discography is the most precise test to localize the level of pathology. Multiple design criteria have been proposed for an ideal intervertebral prosthesis which included endurance, materials behavior, geometry, kinematics, dynamics, motion constraints, fixation to bones and safety. The development of artificial disc technology has culminated into two types of disc replacements, namely total disc replacement and a nucleus pulposus replacement. In addition, four prosthetic models have been proposed which include hydraulic, elastic, composite, and mechanical. Clinical outcomes of total disc replacement and nucleus replacement have been variable. This review describes natural history of disc disease and the diagnostic process, anatomical and biomechanical considerations, design criteria for an ideal intervertebral prosthesis, evolution of artificial disc prosthesis, clinical outcomes of the total disc and nucleus replacement, and prospects and meridians for future research.

The intervertebral foramen serves as the doorway between the spinal canal and periphery. It lies between the pedicles of neighboring vertebrae at all levels in the spine. A number of categorization schemes have been attempted to describe the boundaries of the intervertebral foramen. No uniform agreement has been made on which classification best describes this area. Studies of the nerve root canals have clearly noted variations in the angle of take-off from the thecal sac, length of the nerve root, and placement of the dorsal root ganglion from different lumbar levels. The nerve root canal receives a dual blood supply from central and peripheral sources. The dorsal root ganglion also has a dual vascular supply that aids in preventing damage to this vital foraminal structure. The presence of ligamentous structures within the foramen has been demonstrated by a number of recent studies. These ligaments serve a protective and organizational role for the neurovascular structures of the foramen. A thorough knowledge of the intervertebral foramen will allow the understanding of the pathological and degenerative changes that cause compression or injury to these foraminal structures.

Weakness of the dorsiflexor muscles of the foot is a relatively common presentation. In most cases, the etiology involves a peripheral injury to the common peroneal nerve. These patients usually present with lower motor neuron findings on evaluation. In contrast, if upper motor neuron findings were present a central lesion should be suspected and appropriate imaging studies are performed. We describe a patient with painless foot drop and lower motor findings on examination that was diagnosed with multiple sclerosis. This case demonstrates that multiple sclerosis can masquerade as a peripheral process in some patients.

Study Design: Retrospective chart review., Objective: To report the epidemiologic data of nonsurgical and surgical etiologies of failed back surgery syndrome (FBSS) from two outpatient spine practices., Summary of Background Data: FBSS has been offered as a diagnosis, but this is an imprecise term encompassing a heterogeneous group of disorders that have in common pain symptoms after lumbar surgery. The current literature primarily diagnoses for the various etiologies of FBSS from a surgical perspective. To our knowledge, there is no study that investigates the myriad of surgical and nonsurgical diagnoses from a nonsurgical perspective., Methods: Specific inclusion and exclusion criteria were developed for a list of 42 nonsurgical and surgical differential diagnoses of FBSS. The determination of which category, surgical or nonsurgical, each diagnosis was placed into depended upon the categorization of those diagnoses in previously published literature on FBSS. Each of the authors reviewed the definitions, and they came to a unanimous agreement on each diagnosis' inclusion and exclusion criteria. Data extraction was then carried out in each of the two involved institutions by using the key words discectomy, laminectomy, and fusion to identify all the patients who had any combination of low back, buttock, or lower extremity pain after lumbar discectomy surgery. These charts were then individually reviewed to extract epidemiologic data., Results: A total of 267 charts were reviewed. One hundred and ninety-seven (197) charts had a complete workup. Of these, 11 (5.6%) had an unknown etiology, and 186 had a known diagnosis. Twenty-three (23) various diagnoses were identified. There was approximately an equal distribution between the incidences of nonsurgical and surgical diagnoses; 44.4% had nonsurgical diagnoses and 55.6% had surgical diagnoses. The most common diagnoses identified were spinal stenosis, internal disc disruption syndrome, recurrent/retained disc, and neural fibrosis., Conclusion: FBSS is a syndrome consisting of a myriad of surgical and nonsurgical etiologies. Approximately one half of FBSS patients have a surgical etiology. Approximately 95% of patients can be provided a specific diagnosis.

A 46-year-old patient with left-side low back pain developed symptoms of dysphonia and throat irritation 24 hours after receiving a fluoroscopically guided steroid injection into the epidural space. A direct laryngoscopy performed before a second injection detected no abnormalities. When dysphonia reappeared 48 hours after that injection, laryngoscopy revealed edema in the anterior vocal cord with thick surrounding mucous. Full clinical resolution of the dysphonia was apparent by laryngoscopy 15 days after the second injection. The mechanism of dysphonia after epidural steroid injection is unknown, but it may result from a systemic steroid effect.

Diagnostic SNRIs are a useful tool in the diagnosis of radicular pain in atypical presentations. Diagnostic SNRI is indicated in the following circumstances: (1) for atypical extremity pain; (2) when imaging studies and clinical presentation do not correlate; (3) when electromyography and MRI are not corroborative or are equivocal; (4) for anomalous innervations, such [figure: see text] as conjoint nerve roots or furcal nerves [71]; (5) for failed back surgery syndrome with atypical extremity pain; and (6) for transitional vertebrae. Patients should have demonstrated a failure to improve with less invasive treatment. In these patients, a diagnostic SNRI may localize the pain to a specific spinal nerve. It must be emphasized that the diagnostic SNRI only determines if pain is emanating from a specific nerve root or spinal nerve. A diagnostic SNRI does not determine what has caused the nerve root or spinal nerve pain, nor does it provide prognostic information. The etiology of the nerve root pain, mechanism of injury, underlying anatomy, duration of symptoms, comorbidities, patient desire, physician skill, and a host of other factors determine the appropriate treatment and prognosis.

Current literature and a recent meta-analysis suggest a favorable role for corticosteroid injections in the nonoperative treatment of radiculopathy [70]. The superior results reported in recent literature may be attributable to precise fluoroscopically guided transforaminal placement of injectate close to the disc-nerve root interface and near the dorsal root ganglia, maximizing the therapeutic effect. The favorable results of corticosteroid injections in the treatment of radiculopathy caused by a focal disc herniation are consistent with the biochemical construct of radicular pain. The preliminary unfavorable results of therapeutic SNRB for radicular pain caused by epidural or intraneural fibrosis or occurring after trauma may relate to a biomechanical rather than a biochemical etiology. Outcomes for acquired cervical or lumbar spinal stenosis are intermediate compared with those observed for herniated discs and scarring or trauma. Such results may stem from the multifactorial origin of stenosis symptoms; they may develop from impaired venous flow, restricted neural glide, inflammation, or structural root injury. Better-designed studies that use strict inclusion criteria that stratify patients into categories according to the mechanism of injury (atraumatic versus traumatic), the presence or absence of neurologic deficits or imaging abnormalities, and prior treatment will provide the basis for evidence-based treatment decisions. Such an emphasis is just beginning and inevitably will occur. Until then, decisions have to be predicated on the limited and flawed work conducted to date [71]. Nevertheless, the information gleaned from these published reports provides valuable insight not available just a decade ago.

It is universally accepted that an anatomic abnormality such as a herniated disc or spinal stenosis can lead to radicular leg pain. There is some controversy as to whether radicular pain can be caused by a non-structural, solely biochemical disorder. Prior studies using biochemical analysis of inflammatory mediators of the disc or surrounding structures have enumerated many possible biochemical mediators of radicular pain. However, such studies have not definitively demonstrated whether these inflammatory mediators are the causes of radicular pain or whether these mediators are simply products of the degenerative cascade. The purpose of this paper is to report upon patients who satisfy strict criteria affirming a diagnosis of radiculopathy in the presence of normal imaging studies. The study was designed as a prospective case series of patients fulfilling inclusion and exclusion criteria at a university hospital outpatient physiatric spine practice. Inclusion criteria consisted of symptoms of extremity pain greater than axial pain, examination findings demonstrating a new myotomal deficit that correlates with the root level predicted by the dermatomal pain distribution, and failure to improve after at least 4 weeks of active physical therapy. Magnetic resonance imaging void of local nerve root pathology as per review by the first author and the interpreting radiologist was required. Each patient had to have a positive electromyographic study for an acute radiculopathy. Each patient had to have a positive fluoroscopically guided diagnostic selective nerve root block. In summary, this paper provides clinical evidence that anatomic abnormalities are not required to cause radiculopathy, thus implying that a biochemical etiology is likely to play a significant role in radiculopathy and radicular pain.

The vascular supply of the lumbar vertebral column is a diverse collection of arteries originating from both central and peripheral sites. Until recently, the majority of these studies have been dedicated to the blood supply of the spinal cord and vertebral bodies. More recent effort has been directed toward the identification of the vascular supply to the lumbar nerve roots. These studies have conclusively documented the presence of a dual blood supply to the nerve roots. In addition, this dual vascular supply has been discovered to have the capability for bi-directional flow. This unique property may allow for prevention of localized, compressive ischemic symptoms secondary to either herniated disc material or osteophytes. The nutrient contributions of the cerebrospinal fluid and venous supply to nerve roots have also been investigated. Early studies indicate that they may play a greater role than suspected. The presence of multiple sources of nutrient supply to the lumbar nerve roots enables them to be resistant to the potential compressive phenomenon that may occur in the lumbar spine.

We report the first case of diffuse abnormal insertional activity with bulbar muscle involvement. Electromyography performed 5 months earlier reported multilevel radiculopathy. A repeat electromyography study revealed short trains of positive waves without fibrillation potentials, diffusely present in all tested muscles. Positive waves were also found in the bulbar innervated muscles; these included the trapezius, frontalis, and the orbicularis oculi. This entity is important to recognize because confusion with neuromuscular syndromes can occur., (Copyright 2002 by the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation)

Objective: Describe our experience using discography with intradiscal gadolinium and MR lumbar discography in patients with a history of severe anaphylactoid reaction to iodinated radiocontrast agents., Design: Observational study of 14 patients., Methods: From 1997 to 1999, 14 patients were referred for lumbar discography with intradiscal gadolinium followed by MRI. Patients with a history of a severe anaphylactoid reaction to iodinated radiocontrast media or those who refused the use of iodinated contrast material were included in the study., Results: In fourteen patients, 58 discs were studied. The post discography MRIs identified seven annular tears and seven annular fissures. None of the fourteen patients reported symptoms suggestive of allergic reaction either during or after discography., Conclusions: Discography using intradiscal administration of gadolinium followed by MRI provides a method of obtaining a clinically pertinent study in a subset of patients who likely would not be offered the procedure, secondary to severe anaphylactoid reactions to iodinated contrast materials.

Prostate cancer is the most commonly diagnosed cancer and the second most common cause of cancer death among American men. To our knowledge, the highest reported prostate specific antigen (PSA) level on initial presentation is 3280 ng/mL. In this case report, we discuss a 46-year-old African-American man with back pain of 1-month's duration. A magnetic resonance imaging study of the lumbar spine revealed numerous osseous metastatic lesions, and the PSA level was found to be 5666 ng/mL. He was treated with oral narcotics and a Duragesic patch to achieve analgesia and bicalutamide (Casodex) and leuprolide acetate (Lupron) therapy for androgen blockade. Later in his course, he required chemotherapy due to hormone-refractory prostate cancer. The patient has done well as shown at his latest follow-up at 48 months. The objective of this report is to discuss the first patient with metastatic prostate cancer to the spine with PSA level greater than 3,500 ng/mL.

Back injury is one of the most frequently encountered injuries in the collegiate rower. The differential diagnosis of back pain in the competitive rower includes muscle strain, ligament/tendon injury, stress reaction, stress fracture, and a tear in the annulus fibrosis. Endurance sports, such as rowing, have an increased frequency of stress injury The diagnosis of stress reaction cannot be made with plain radiographs. Many studies have firmly established the efficacy of single photon emission computed tomography (SPECT) bone scans and magnetic resonance imaging in establishing the diagnosis of a stress reaction We present a case of a collegiate rower with mid back pain secondary to a stress reaction of the endplates of the costotransverse articulation at the T8 level diagnosed by a positive positron emission tomogram study in the setting of a negative SPECT scan.

Biochemical mechanisms to explain pain generation began relatively recently. Evaluating pain originating from the spine can be challenging because no historical or physical examination findings are sufficiently sensitive or specific for identifying each of the myriad of potential pain generators. These discrete anatomic structures include the nerve root, disc annulus, posterior longitudinal ligament, sacroiliac joint, and facet joint. The diagnostic selective nerve root block is a useful test to determine the etiology of pain when other testing is inconclusive. If a patient with radicular symptoms has non-corroborative visual anatomic and neurophysiologic testing, diagnostic selective nerve root block may elucidate the level of pain generation. Also, in a patient with multiple abnormalities on visual anatomic testing, the lesion of clinical significance can be identified. However, this test may not be necessary in the patient when the specific radiculopathy level diagnosis is apparent; this is the case when a characteristic history and physical examination have a corroborative single-level imaging lesion. Determining which level is generating symptoms has implications for subsequent physical therapy, therapeutic injections, and surgery. This review of selective nerve root blocks describes the relevant anatomy, pathophysiology, rationale, clinical utility, and complications.

Failed back surgery syndrome (FBSS) is a long-lasting, often disabling, and relatively frequent (5%-10%) complication of lumbosacral spine surgery. Epidural fibrosis is among the most common causes of FBSS, and it is often recalcitrant to treatment. Repeated surgery for fibrosis has only a 30% to 35% success rate, whereas 15% to 20% of patients report worsening of their symptoms. Long-term outcome studies focusing on pharmacologic management of chronic back pain secondary to epidural fibrosis are lacking in the literature. This report presents 2 cases of severe epidural fibrosis managed successfully with gabapentin monotherapy. In both cases, functional status improved markedly and pain was significantly diminished. Gabapentin has an established, favorable safety profile and has been shown to be effective in various animal models and human studies of chronic neuropathic pain. Clinicians should consider gabapentin as a pharmacologic treatment alternative in the management of FBSS caused by epidural fibrosis.

Study Design: A retrospective chart review., Objectives: To report the correlation between the side of a concordantly painful, post-discography computer tomography (CT) visualized, annular tear, and the side of a patients' low back pain., Summary of Background Data: An annular fissure extending from the nucleus to the outer one-third of the annulus is thought to be the nociceptive source stimulated during provocative lumbar discography. To our knowledge, there are no studies that have attempted to delineate whether the side of the annular tear correlates with the side of the patient pain., Methods: One hundred and one post-discography CT scans, performed on patients with single level, concordantly painful, and fissured discs identified during lumbar discography, were randomly obtained from the archived and current files of the Penn Spine Center's film library. These were reviewed by both the lead author and a spine radiologist, both of who were blinded to the side of the patients pain, to determine which scans demonstrated clearly definable tears extending to the outer one-third of the annulus. Statistical analysis via the exact method was used to determine the correlation between the side of the patients tear and the side of the patients pain., Results: Forty post-discography CT scans met the inclusion criteria. There was a random correlation between the side of the patients concordantly painful annular tear and the side of the patients pain., Conclusions: The results of this study raise several questions regarding the embryologic development of the intervertebral disc and its somite, neurologic transmission of discogenic pain, distribution of chemical inflammagens, validity of discography, technique of ESI, and technique and validity of IDET.

The sacroiliac joint has long been considered to be a potential source of low back and/or buttock pain with or without lower extremity symptoms. Until recently, supportive evidence for this disorder has been empirical as it was solely derived from information garnered from patients who obtained successful treatment for a constellation of signs, symptoms and examination findings believed to be indicative of sacroiliac joint syndrome. Due to this fallacious reasoning, successful treatment denotes a correct diagnosis; many of the concepts espoused during the past few decades have been predicated upon spurious data. With the advent of and systematic utilization of fluoroscopically guided diagnostic sacroiliac joint blockade specific epidemiologic, symptomatic, examination, diagnostic, and outcome data have been derived. This review describes current concepts and provides information that expounds and, in some instances, supplants prior held notions about this disorder.

This study was designed to investigate the clinical efficacy of fluoroscopically guided therapeutic cervical selective nerve root blocks (SNRBs) in patients with whiplash induced cervical radicular pain. Study design was restrospective with independent clinical review. Twenty two patients were included. Each patient met specific physical examination criteria and failed to improve clinically after at least four weeks of physical therapy and the use of oral analgesics. Each patient demonstrated a positive response to a fluoroscopically guided diagnostic cervical SNRB. Patients were excluded for radiographic evidence of a focal disc protrusion or foraminal stenosis at the symptomatic level. Therapeutic cervical SNRBs were administered in conjunction with physical therapy. Data collection and analysis were performed by an independent clinical reviewer. Outcome measures included VAS pain scores, work status, medication usage, and Oswestry disability scores. Results showed the patients' symptom duration prior to diagnostic injection averaged 6 months. An average of 2.1 therapeutic injections was administered. Follow up data collection transpired at an average of 33.3 weeks following the final therapeutic injection. Good or excellent results were observed in 14% of patients. In higher functioning individuals a significantly greater (F=.0427) improvement in pain of 48.9% was observed. In these initial findings suggest that fluoroscopically guided therapeutic SNRBs, except possibly for higher functioning individuals, are not effective in the treatment of whiplash induced cervical radicular pain.