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Chronic sciatica is a major cause of disability worldwide, but accurate diagnosis of the causative pathology remains challenging. In this report, the feasibility of an 18 F-FDG PET/MRI approach for improved diagnosis of chronic sciatica is presented. Methods: 18 F-FDG PET/MRI was performed on 9 chronic sciatica patients and 5 healthy volunteers (healthy controls). Region-of-interest analysis using SUV max was performed, and 18 F-FDG uptake in lesions was compared with that in the corresponding areas in healthy controls. Results: Significantly increased 18 F-FDG uptake was observed in detected lesions in all patients and was correlated with pain symptoms. 18 F-FDG-avid lesions not only were found in impinged spinal nerves but also were associated with nonspinal causes of pain, such as facet joint degeneration, pars defect, or presumed scar neuroma. Conclusion: The feasibility of 18 F-FDG PET/MRI for diagnosing pain generators in chronic sciatica was demonstrated, revealing various possible etiologies., (© 2018 by the Society of Nuclear Medicine and Molecular Imaging.)

Objective: To determine the relationship among spinal stenosis, back pain, paraspinal muscle denervation, and paraspinal muscle atrophy., Design: A prospective masked, double-controlled study., Setting: A university hospital and outpatient spine clinic., Participants: Ten asymptomatic subjects, 10 subjects with mechanical low back pain, and 15 subjects with symptomatic spinal stenosis; age range, 55-80 years old., Interventions: Magnetic resonance imaging measurements of minimum spinal canal diameter, paraspinal muscle cross-sectional area at the level of the L5-S1 disk, and quantified paraspinal electrodiagnostic testing (MiniPM) were performed by examiners blinded to each other's results and to the participants' clinical information., Main Outcome Measurements: Paraspinal muscle cross-sectional area and MiniPM scores., Results: A paraspinal cross-sectional area decreased significantly from asymptomatic subjects (3872 mm(2)) to subjects with low back pain (3627 mm(2)) and to subjects with spinal stenosis (2985 mm(2)). In the stenosis group, there was a trend toward increased paraspinal denervation in the subjects with severe spinal stenosis, but this was not statistically significant., Conclusions: Symptomatic spinal stenosis results in greater paraspinal muscle atrophy than low back pain alone. The extent of paraspinal atrophy was not significantly explained by the extent of denervation, thus, it may be reversible, and the role of paraspinal muscle rehabilitation in patients with spinal stenosis deserves further study., (Copyright © 2013 American Academy of Physical Medicine and Rehabilitation. Published by Elsevier Inc. All rights reserved.)

Background Context: Vascular etiologies are a significant source of radiculopathy. The entities that are reviewed here include epidural spinal hematoma, subdural spinal hematoma, spinal arteriovenous malformation, vertebral hemangioma, spinal epidural cavernous hemangioma, vertebral artery anomalies (both tortuosity and dissection), aortic aneurysm, hemorrhagic synovial cysts, ligamentum flavum hematoma, and venous varices. The incidence, pathophysiology, typical clinical presentation, appropriate diagnostic workup, and management are summarized., Purpose: To review and summarize various vascular causes of radiculopathy and how it impacts the management of patients with radicular spinal pain., Study Design: Literature review., Methods: An extensive literature review was done on each of the vascular entities and their presentation as radiculopathy., Results: Vascular etiologies of radiculopathy may be underestimated in the literature. Imaging in addition to the history and physical examination is essential to identifying vascular sources of radiculopathy and establishing correct treatment., Conclusions: In examining patients with radicular pain, extraspinal causes of radiculopathy including vascular entities should be included in the differential. Knowledge of the incidence, pathophysiology, clinical presentation, and management of the possibly underreported various vascular causes of radiculopathy increase the ability of the physician to provide optimal care for the patient. A key aspect to identifying such vascular lesions is appropriate imaging for documenting the source of radiculopathy. Blind injections, done without appropriate imaging for identifying the cause of radiculopathy, and also performed without fluoroscopic guidance, increase not only the risk of misdiagnosis but also the comorbidities associated with spinal injections., (Copyright © 2011 Elsevier Inc. All rights reserved.)

Backgroud Context: Low back pain can be difficult to diagnose, leaving patients frustrated and confused after medical visits.Purpose: To evaluate the importance of reasons for seeking care in patients with back pain, and to compare this to physicians' assumptions about these patients' reasons.Study Design/setting: Prospective survey study carried out at two academic spine centers.Patient Sample: A sum of 419 patients with back pain upon initial presentation to a spine clinic, and 198 physicians; all volunteered to complete a survey.Outcome Measures: Variance in mean values between patient and physician responders with significance determined by non-overlapping 95% confidence intervals.Methods: Patients were asked to "rate each of the following with regard to their importance to you" (answering between 0 "not important" to 4 "extremely important"): improvement in level of pain, improvement in ability to perform daily tasks, explanation of what is causing your problem, thorough physical examination, diagnostic testing, medication, physical therapy, surgery. Physicians were asked to rate each of these "with regard to their importance to your patients."Results: Patients indicated the following items were the most important (mean values): explanation of what is causing your problem (3.27), improvement in level of pain (3.48) and improvement in ability to perform daily tasks (3.31). Patients attributed the least importance and lowest scores to: surgery (1.07) and medication (1.89). Comparing the mean values to each item by patient and physician responders revealed statistically significant differences in certain items. Specifically, physicians underestimated the importance of an explanation of what is causing the problem (2.78±0.119 vs. 3.28±0.098, 95% CI) and overvalued diagnostic tests (2.64±0.120 vs. 2.30±0.147, 95% CI), medications (2.38±0.118 vs. 1.89± 0.143, 95% CI) and surgery (1.60±0.126 vs. 1.07±0.140, 95% CI).Conclusion: Patients did not place as much importance on diagnostic tests, medications and surgery as the physicians assumed. Physicians understand that back pain patients want improvement in both pain and function, but they underestimate the importance of an explanation for the pain. [ABSTRACT FROM AUTHOR]

Recently, basivertebral nerve (BVN) radiofrequency ablation has been developed for the treatment of chronic low back pain (CLBP) thought to arise from the vertebral body endplates (VEPs). This review describes the relevant neuroanatomy and pathobiology of VEP degeneration and injury, imaging correlates of presumed VEP pain, randomized controlled trials performed, appropriate patient selection, and safety. Anatomic, histological, and clinical evidence supports the concept of the VEP as a source of CLBP and the nociceptive role of the BVN. BVN radiofrequency ablation appears to be an effective treatment for a subset of patients with CLBP and evidence of Modic change types 1 and 2 in the L3 to S1 VEPs who have failed to respond to conservative treatment. However, all studies performed to date have been industry sponsored, and future non–industry-funded trials will be needed to confirm these results. [ABSTRACT FROM AUTHOR]

Objective Examine the interrelationship between smoking and pain in the US population. Design A cross-sectional population-based study. Setting Nationwide survey. Methods Comprehensive pain reports categorically defined as head, spine, trunk, and limb pain; smoking history; demographics; medical history from a total of 2,307 subjects from the 2003–2004 National Health and Nutrition Examination Survey obtained from the Centers for Disease Control were analyzed. Unpaired t tests were used to analyze independent continuous variables, and chi-square tests were used to analyze categorical variables between smoker and nonsmoker groups. Weighted multivariate logistic regression analyses determined the association of current smoking with the presence of pain in various body regions. Results Smoking is most strongly associated with spine pain (odds ratio [OR] = 2.89, 95% confidence interval [CI] = 2.21–3.77), followed by headache (OR = 2.47, 95% CI = 1.73–3.53), trunk pain (OR = 2.17, 95% CI = 1.45–2.74), and limb pain (OR = 1.99, 95% CI = 1.45–2.73). Conclusions Current smoking is associated with pain in every region of the body. This association is strongest for spine and head pain. Given that pain is a strong motivator and that current smoking was associated with pain in all body regions, we recommend that these results be used to further raise public awareness about the potential harms of smoking. [ABSTRACT FROM AUTHOR]

Objective: The purpose of this review was to identify risk factors, prognostic factors, and comorbidities associated with common spinal disorders. Methods: A scoping review of the literature of common spinal disorders was performed through September 2016. To identify search terms, we developed 3 terminology groups for case definitions: 1) spinal pain of unknown origin, 2) spinal syndromes, and 3) spinal pathology. We used a comprehensive strategy to search PubMed for meta-analyses and systematic reviews of case-control studies, cohort studies, and randomized controlled trials for risk and prognostic factors and cross-sectional studies describing associations and comorbidities. Results: Of 3,453 candidate papers, 145 met study criteria and were included in this review. Risk factors were reported for group 1: non-specific low back pain (smoking, overweight/obesity, negative recovery expectations), non-specific neck pain (high job demands, monotonous work); group 2: degenerative spinal disease (workers’ compensation claim, degenerative scoliosis), and group 3: spinal tuberculosis (age, imprisonment, previous history of tuberculosis), spinal cord injury (age, accidental injury), vertebral fracture from osteoporosis (type 1 diabetes, certain medications, smoking), and neural tube defects (folic acid deficit, anti-convulsant medications, chlorine, influenza, maternal obesity). A range of comorbidities was identified for spinal disorders. Conclusion: Many associated factors for common spinal disorders identified in this study are modifiable. The most common spinal disorders are co-morbid with general health conditions, but there is a lack of clarity in the literature differentiating which conditions are merely comorbid versus ones that are risk factors. Modifiable risk factors present opportunities for policy, research, and public health prevention efforts on both the individual patient and community levels. Further research into prevention interventions for spinal disorders is needed to address this gap in the literature. [ABSTRACT FROM AUTHOR]

Setting. Interventional procedures directed toward sources of pain in the axial and appendicular musculoskeletal system are performed with increasing frequency. Despite the presence of evidence- based guidelines for such procedures, there are wide variations in practice. Case reports of serious complications such as spinal cord infarction or infection from spine injections lack appropriate context and create a misleading view of the risks of appropriately performed interventional pain procedures. Objective. To evaluate adverse event rate for interventional spine procedures performed at three academic interventional spine practices. Methods. Quality assurance databases at three academic interventional pain management practices that utilize evidence-based guidelines [1] were interrogated for immediate complications from interventional pain procedures. Review of the electronic medical record verified or refuted the occurrence of a complication. Same-day emergency department transfers or visits were also identified by a records search. Results. Immediate complication data were available for 26,061 consecutive procedures. A radiology practice performed 19,170 epidural steroid (primarily transforaminal), facet, sacroiliac, and trigger point injections (2006-2013). A physiatry practice performed 6,190 spine interventions (2004-2009). A second physiatry practice performed 701 spine procedures (2009-2010). There were no major complications (permanent neurologic deficit or clinically significant bleeding [e.g., epidural hematoma]) with any procedure. Overall complication rate was 1.9% (493/26,061). Vasovagal reactions were the most frequent event (1.1%). Nineteen patients (<0.1%) were transferred to emergency departments for: allergic reactions, chest pain, symptomatic hypertension, and a vasovagal reaction. Conclusion. This study demonstrates that interventional pain procedures are safely performed with extremely low immediate adverse event rates when evidence-based guidelines are observed. [ABSTRACT FROM AUTHOR]

Objective. It has been postulated that local anesthetic administration may be the most painful part of interventional spine procedures. Despite this, there is a lack of evidence supporting the commonly used traditional technique of anesthetic delivery as part of these procedures. This study tested three hypotheses: 1) alternative method of local anesthesia injection is superior to the traditional method; 2) using the traditional method of injection is not superior to using no local anesthetic; and 3) treatment needle size, anesthetic injection technique, and sedation are associated with pain experienced during procedures. Design. Prospective, multicenter clinical trial of 127 participants who underwent elective bilateral symmetric interventional spine procedures in outpatient spine clinics. Methods. Primary outcomes were pain scores during and after procedures to examine the influence of anesthetic injection method and treatment needle gauge on pain experience using linear mixed model regression analysis. A post-hoc comparison of estimated marginal mean pain scores was completed on both anesthetic injection method and treatment needle gauge. Conclusions. The alternative method was superior (P< 0.05) to the traditional method on post procedural pain scores. Injecting local anesthetic with the traditional or alternative method was not superior to using no local anesthetic. Treatment needle size, pain at one inch of treatment needle insertion, and baseline pain were all significantly (P< 0.05) associated with overall procedural pain. Further studies are needed optimize and justify local anesthetic injections for these procedures. [ABSTRACT FROM AUTHOR]

Background. Transforaminal epidural steroid injections (TFESI) have demonstrated efficacy and effectiveness in treatment of radicular pain. Despite little evidence of efficacy/effectiveness, interlaminar epidural steroid injections (ILESI) are advocated by some as primary therapy for radicular pain due to purported greater safety. Objective. To assess immediate and delayed adverse event rates of TFESI and ILESI injections at three academic medical centers utilizing International Spine Intervention Society practice guidelines. Methods. Quality assurance databases from a Radiology and two physical medicine and rehabilitation (PM&R) practices were interrogated. Medical records were reviewed, verifying immediate and delayed adverse events. Results. There were no immediate major adverse events of neurologic injury or hemorrhage in 16,638 consecutive procedures in all spine segments (14,956 TFESI; 1,682 ILESI). Vasovagal reactions occurred in 1.2% of procedures, more frequently (P=0.004) in TFESI (1.3%) than ILESI (0.5%). Dural punctures occurred in 0.06% of procedures, more commonly after ILESI (0.2% vs 0.04%, P=0.006). Delayed follow up on PM&R patients (92.5% and 78.5, next business day) and radiology patients (63.1%, 2 weeks) identified no major adverse events of neurologic injury, hemorrhage, or infection. There were no significant differences in delayed minor adverse event rates. Central steroid response (sleeplessness, flushing, nonpositional headache) was seen in 2.6% of both TFESI and ILESI patients. 2.1% of TFESI and 1.8% of ILESI patients reported increased pain. No long-term sequelae were seen from any immediate or delayed minor adverse event. Conclusions. Both transforaminal and ILESI are safely performed with low immediate and delayed adverse event rates when informed by evidence-based procedural guidelines. By demonstrating comparable safety, this study suggests that the choice between ILESI and TFESIs can be based on documented efficacy and effectiveness and not driven by safety concerns. [ABSTRACT FROM AUTHOR]

Background Vasovagal reactions can occur with spine procedures and may result in premature procedure termination or other adverse events. Objective To evaluate if moderate sedation is an effective means of secondary prevention for vasovagal reactions. Methods Prospectively collected data on 6,364 consecutive spine injections. Results Of the 6,364 spine injections, 6,150 spine injections were done without moderate sedation and resulted in 205 vasovagal reactions (3.3% [95% confidence interval { CI} 2.9-3.8%]). One hundred thirty-four spine procedures were performed on patients that had a history of prior vasovagal reaction during a spine procedure. Of these, 90 procedures were performed without moderate sedation, and 21/90 (23.3% [95% CI 15.2-32.1%]) were complicated by a repeat vasovagal reaction. None of 44 repeat injections that utilized moderate sedation experienced a repeat vasovagal reaction (0% [95% CI 0-9.6%]) (χ2 = 12.17, P < 0.00048). The rate of vasovagal reaction in patients with a history of prior reaction undergoing repeat injection without conscious sedation was significantly higher (23.3% [95% CI 15.2-32.1%]) than the rate in patients with no such history (3.0% [95% CI 2.6-3.5%] [χ2 = 113.4, P < 1.78 E-26]). Conclusions A history of vasovagal reaction is a strong predictor of experiencing a vasovagal reaction on subsequent procedures. No vasovagal reactions occurred with the use of moderate sedation, including in the 44 injections in patients that had a history of vasovagal reaction during spine procedures. The overall low rate of vasovagal reactions is low, and greater benefits of moderate sedation were observed when utilized as secondary prevention of repeat vasovagal reactions. [ABSTRACT FROM AUTHOR]

Abstract: Background context: Reports of serious complications from cervical transforaminal epidural corticosteroid injections often consider accidental intra-arterial injection the most likely mechanism of injury. As a result, many physicians have instituted methods to prevent intravascular injections. Routine use of the anesthetic test dose is one such method. The utility of the anesthetic test dose in this function has not been characterized in the current literature. Purpose: The aim of this study was to determine the utility of injecting an anesthetic test dose before cervical transforaminal epidural corticosteroid injection and estimate the rate of false-negative intravascular contrast injection using live fluoroscopy and digital subtraction angiography (DSA). Study design: Two-center retrospective study. Patient sample: A consecutive cohort of men and women, ages of 23 to 83, who underwent cervical transforaminal epidural injection and received the anesthetic test dose after contrast injection was negative for vascular uptake, observed using live fluoroscopy or DSA. Outcome measures: Response to the anesthetic test dose was documented in each procedure note and recorded as either positive or negative. Methods: Records of three physiatrists at two academic spine centers (Center A and Center B) were reviewed to identify all patients who received a cervical transforaminal epidural injection during the preceding 5 years, resulting in a cohort of consecutively treated patients at each center. Each patient record was reviewed for demographics, indication for injection, procedure level and side, needle gauge, use of DSA, volume and type of anesthetic test dose used, and result of test dose injection. The test dose was considered positive if the following occurred: agitation or other sudden central nervous system change; gross motor deficits and/or paresthesias in the trunk, legs, or contralateral arm; systemic symptoms of anesthetic toxicity including cardiac arrhythmia, perioral numbness, metallic taste, dizziness, and/or ringing in the ear. For analysis, injections were separated into groups to compare results at Center A to Center B and to compare injections that used DSA to those that did not. The incidence of a positive response was calculated as a percentage from the total number of injections in the group. Differences between groups were analyzed for statistical significance using the Fisher exact test. Results: Six hundred seventy-eight injections were included. Of these, 349 were performed at Center A with test doses given after contrast injection under live fluoroscopy. The remaining 329 were performed at Center B, 183 also using live fluoroscopy, and 146 using DSA. The overall incidence of a positive anesthetic test dose was 0.59% (4/678). There was no significant difference between the incidence at each of the two centers (0.86% [3/349] vs. 0.30% [1/329]; p=.63). The overall incidence after live fluoroscopy was 0.75% (4/532) and after DSA was 0% (0/146), but this difference was not statistically significant (p=.58). Positive symptoms elicited by test dose administration included midneck and contralateral arm pain, metallic taste, dizziness, tachycardia, full body paresthesias, auditory changes, slurred speech, and motor ataxia. In all four cases with a positive response, the procedure was immediately terminated, symptoms resolved, and no lasting complications were observed. Conclusions: The routine use of an anesthetic test dose appears to be safe and capable of detecting potentially dangerous intravascular injections undetected by conventional techniques. Positive responses occur in a small portion of those who receive the test dose injection. Further studies are required to determine the optimal dose and concentration of anesthetic to be used and the time required for observation after test dose administration. [Copyright &y& Elsevier]

Abstract: Background context: Vascular penetration and injection of corticosteroids into a vessel during lumbosacral transforaminal epidural injection is a suspected cause of myelopathy. Blunt needles have been suggested to avoid vascular penetration, but they are difficult to navigate. Another alternative to the standard long-bevel sharp needles is the short-bevel needles. Some have postulated that short-bevel needles are the best option for high-risk spine injections because they maintain navigation characteristics while potentially reducing the risk of complications. To date, no studies have been performed to either confirm or refute this. Purpose: The purpose of this study was to determine if there is a difference in the incidence of vascular penetration during lumbosacral transforaminal epidural injections between short-bevel and long-bevel needles. Study design/setting: This is a prospective, observational, in vivo study. Patient sample: The sample comprises patients receiving lumbosacral transforaminal epidural injections at a university-based outpatient spine center. Outcome measure: The outcome measure was the incidence of vascular contrast patterns observed under live fluoroscopy. Methods: One interventional spine physician recorded contrast patterns observed during 158 fluoroscopically guided lumbosacral transforaminal epidural injections under live fluoroscopy using two different types of needle tips. Results: Vascular injections were observed in 22 of the 158 injections, for an overall incidence of 13.9%. The incidence of vascular injections in the short-bevel group was 15.6% (10/64) and in the long-bevel group was 12.8% (12/94). This difference was not statistically significant (p=.6447). A secondary analysis was performed to determine if the needle gauge influenced the incidence of vascular injections, and again, there were no statistical differences in the overall rates of vascular injection. Conclusions: In comparison with long-bevel needles, short-bevel needles do not reduce the risk of inadvertent vascular injection in lumbosacral transforaminal epidural injections. [Copyright &y& Elsevier]

Objective. Report a case of intravascular contrast injection during lumbar discography. Setting. An academic University spine center. Patient. Forty-year-old woman with L5-S1 degenerative disk disease and persistent low back pain. Intervention. The patient failed to respond to multiple conservative treatments. In consideration of surgical treatment, discography was requested. Results. A 22G needle was inserted to the central nucleus by a left posterolateral approach. Discography was performed at L4-5 and L5-S1. Testing was performed with pressure manometry, beginning with the L4-5 disk. The pressure increased with contrast injection in the manner of a normal disk. At 45 psi there was a sudden drop to 20 psi. Lateral views obtained during contrast injection demonstrated flow from a central nucleogram cephalad into the anterior epidural space. Images obtained with live fluoroscopy demonstrated a vascular flow pattern, confirmed with lateral and anterior-posterior views. The needle tip was repositioned anterior and superior. Repeat injection resulted in an identical vascular pattern. From the time the pressure dropped, contrast flowed in the vascular pattern without propagation of the nucleogram or increase in intradiscal pressure. The patient was asymptomatic throughout the injection at L4-5. Injection at L5-S1 demonstrated a severely degenerative nucleogram and reproduced the patient's usual low back pain. Conclusions. Vascular uptake of contrast can occur during lumbar discography, even when the needle tip is ideally located. [ABSTRACT FROM AUTHOR]

Abstract: Background context: The incidence of vascular penetration during contrast confirmed fluoroscopically guided transforaminal lumbosacral epidural injections has been reported as 8.9% to 21.3% depending on the level of injection. Recently, intermittent fluoroscopy was shown to miss more than half of the vascular injections observed under live fluoroscopy. The number of misses increased when epidural and vascular contrast flow appeared simultaneously, even if the fluoroscopic image was taken during contrast injection. To date, no studies have documented the incidence of simultaneous epidural and vascular contrast injections. Also, most previous studies of vascular injections did not document use of live fluoroscopy during contrast injection, so the incidence of vascular injections may be higher than reported. Purpose: To determine the incidence of simultaneous epidural and vascular contrast injection during lumbosacral transforaminal epidural injections. Study design/setting: A prospective, observational, in vivo, study. Patient sample: Patients receiving lumbar transforaminal epidural injections at a university-based outpatient spine center. Outcome measures: Incidence of epidural, vascular, and simultaneous epidural and vascular contrast patterns. Methods: One interventional spine physician and three fellows under his direct supervision recorded contrast patterns observed during 191 fluoroscopically guided lumbosacral transforaminal epidural steroid injections with injection of contrast observed under live fluoroscopy. Results: The incidence of simultaneous epidural and vascular injection during lumbosacral transforaminal epidural injections was 8.9%. The incidence of a vascular injection alone was 4.2%, for a total vascular injection incidence of 13.1%. Subjects with a simultaneous epidural and vascular injection who returned for repeat injection had a statistically significant chance of a repeat simultaneous epidural and vascular injection when the injection was done at the same location. Fluoroscopy time was significantly increased, an average of 8.8 seconds, when a vascular injection was identified. There was no statistically significant correlation between the incidence of simultaneous epidural and vascular injection with subjects'' age, sex, level of injection, side of injection, needle gauge, or diagnosis. Conclusions: Simultaneous epidural and vascular injection is twice as likely to occur as vascular injection alone. Use of intermittent fluoroscopy can miss the transient appearance of the vascular component of these injections, giving the false impression of successful contrast placement. In light of these results, live fluoroscopy is recommended during contrast injection for confirmation of lumbosacral transforaminal epidural injections. [Copyright &y& Elsevier]

Commentary On: Matthew L. Stevens, Chung-Wei C. Lin, Flavia A. de Carvalho, Kevin Phan, Bart Koes, Chris G. Maher. Advice for acute low back pain: A comparison of what research supports and what guidelines recommend. The Spine Journal, In Press. [ABSTRACT FROM AUTHOR]