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Poster 266: The Effect of Needle Position and Contrast Spread Pattern on Outcome of Lumbar Transforaminal Epidural Steroid Injections
E106
ACADEMY ANNUAL ASSEMBLY ABSTRACTS
Poster 266 The Effect of Needle Position and Contrast Spread Pattern on Outcome of Lumbar Transforaminal Epidural Steroid Injections. Ai Mukai, MD (David Geffen School of Medicine, University of California, Los Angeles, CA); Howard Dedes, MD; David E. Fish, MD, MPH. Disclosure: H. Dedes, none; D.E. Fish, none; A. Mukai, none. Objective: To determine if medication delivery into epidural space confirmed by contrast enhancement fluoroscopic images is superior to a neurogram placement; to determine if lumbar transforaminal epidural steroid injections needle position can effect contrast spread pattern and outcome. Design: Prospective, evaluator-blind clinical trial. Setting: Outpatient multidisciplinary spine care center. Participants: 50 patients with L4 and/or L5 radiculopathy who failed conservative management. Interventions: L4-L5 and/or L5-S1 lumbar transforaminal epidural steroid injections. Main Outcome Measures: A survey that included Verbal Rating Scale (VRS), visual analog scale (VAS), Oswestry Disability Index (ODI), Hospital Anxiety and Depression Scale (HADS), and Pain Catastrophizing Scale (PCS). Fluoroscopic radiographs reviewed by a radiologist blinded to the patient and outcome to identify needle position (AP/lateral views) and contrast flow. With the AP view, the radiologist determined the needle point to be at medial or lateral by using the 6 o’clock position as midline. In the lateral view, the location of the needle tip was classified as 12 o’clock, 3 o’clock, 6 o’clock, or 9 o’clock position. Results: 68% of patients were women and 32% were men, with average age ⫾ SD of 56.7⫾14.9 years (range, 19 – 86y). At the L4-L5 level, 58% were neurograms, 0% epidural only, and 26% with both patterns. At the L5-S1 level, 48% were neurograms, 6% epidural, and 44% had both patterns. There were no statistically significant differences between needle position and functional outcome using the VRS, VAS, and ODI. There appeared to be a trend for better outcome as measured by change in VRS, VAS, HADS, and ODI for epidural contrast pattern. Interestingly, there was a trend for worse PCS scores in the epidural group when compared with the neurogram-only group. Conclusions: These findings suggest that there is no benefit in functional outcome as related to needle position within the foramina. It is likely that regardless of needle position, epidural spread of the medication is the more important factor in functional improvement with lumbar transforaminal epidural steroid injections. Limitations include small sample size and possible overlapping effect with multi-level injections. Further studies with larger sample size are needed to address outcome improvement in correlation with fluoroscopic images. Key Words: Injections; Radiculopathy; Rehabilitation. Poster 267 The Incidence of Intravascular Needle Placement While Performing Medial Branch Nerve Blocks in the Lumbar Spine. Benjamin R. Humpherys, DO (Southwest Spine & Sport, Scottsdale, AZ); Jonathon C. Komar, MD; Anthony A. Lee, MD; Michael J. Simek, MD; Michael W. Wolff, MD. Disclosure: B.R. Humpherys, none; J.C. Komar, none; A.A. Lee, none; M.J. Simek, none; M.W. Wolff, none. Objective: To record the incidence of intravascular needle placement during fluoroscopically guided, contrast-enhanced, medial branch nerve blocks performed at the zygapophyseal joints in the lumbar spine. Design: A prospective, observational study. Setting: Ambulatory surgery center. Participants: Private practice patients with a chief complaint of axial low back pain, clinical signs, and radiographic findings suggestive of zygapophyseal joint-mediated pain. Interventions: 361 consecutive fluoroscopic-guided nerve blocks of the L2, L3, and L4 medial branch nerves and the L5 dorsal rami were performed using International Spine Intervention Society practice guidelines protocol. Once proper needle placement was established, the presence or absence of intravascular needle-tip placeArch Phys Med Rehabil Vol 89, November 2008
ment was identified by the performing physician while injecting contrast dye through the needle during live fluoroscopy. Main Outcome Measures: The lumbar level and side-specific presence of vascular flow of contrast injected under live fluoroscopy. Results: In 361 lumbar medial branch nerve blocks, the overall rate of intravascular needle placement was 13.6%. The level with the highest incidence was L4 (18.2%). The level with the lowest incidence was L5 (6.0%). There was no significant side-to-side difference at each respective lumbar nerve level. Conclusions: There is a significant incidence of intravascular needle placement using standard medial branch nerve block techniques, especially at the L4 medial branch nerve level. Performing medial branch nerve blocks without fluoroscopic confirmation of contrast flow may lead to intravascular administration of medication and may therefore potentially lead to an increase in false negative results and/or potential health risks to patients undergoing these procedures. Key Words: Low back pain; Rehabilitation; Zygapophyseal joint. Poster 268 The Role of Cervical C1/2, C2/3 Spinal Injections in the Diagnosis of Cervicogenic Headache. Linqiu Zhou, MD (Thomas Jefferson University, Philadelphia, PA); Ronnen Abramov, DO; Avi Ashkenazi, MD. Disclosure: R. Abramov, none; A. Ashkenazi, Merck Inc, research grants; L. Zhou, none. Objective: The diagnosis and treatment of cervicogenic headache (CEH) is challenging. This study was to determine the role of C1-C2 and C2-C3 facet joint and dorsal ramus injections in diagnosis of CEH. Design: Retrospective study. Setting: Academic pain center. Participants: 30 patients with clinical diagnosis of CEH, 13 men and 17 women; mean age of 42 years (range, 18 – 65y). All patients had failed multiple pharmacologic and other treatments prior to the study. Average disease duration was 6.9 (0.5–20) years. 10 patients had a unilateral headache and 20 had bilateral headache. All patients underwent a cervical magnetic resonance imaging (MRI). In 26 patients, the MRI demonstrated degenerative disk disease or a herniated disk, most commonly at C5-C6. Interventions: All patients underwent fluoroscopic-guided C1-C2, C2-C3 facet joint injections and C2-C3 dorsal ramus injections. Main Outcome Measures: Numerical pain scale, duration of pain relief (days). Results: 27 out of 30 (90%) patients experienced greater than 50% headache relief, with an average duration of 26 (2–90) days from the first injection. C1-C2 and C2-C3 injections provided a long duration of pain relief. Three patients who did not respond to the injection were finally diagnosed with another type of headache. The response to C1-C2 and C2-C3 injections supports the diagnosis of CEH. Conclusions: C1-C2 and C2-C3 facet joint and dorsal ramus blocks provided significant and prolonged pain relief in the majority of patients in this study. The procedure also plays an important role in diagnosis of CEH. If a patient fails to respond to these injections, another type of headache should be considered. Further randomized studies are needed to compare the sensitivity and specificity of blocking the facet joints versus the dorsal rami in the diagnosis of patients with CEH. Additionally, studies are needed to assess the sensitivity and specificity of the diagnosis in a controlled manner. Key Words: Rehabilitation; Spinal injection. Poster 269 Titration of Oxymorphone Extended Release in Opioid-Experienced Patients With Chronic Low Back Pain Due to a Herniated Disk or Degenerative Disk Disease. Martin E. Hale, MD (Gold Coast Research, LLC, Weston, FL); Harry Ahdieh, PhD; Rosemary Kerwin, PharmD; Tina Ma, PhD. Disclosure: H. Ahdieh, Endo Pharmaceuticals, employment; M.E. Hale, Endo Pharmaceuticals, Inc, research grants; R. Kerwin, Endo
ACADEMY ANNUAL ASSEMBLY ABSTRACTS
Poster 266 The Effect of Needle Position and Contrast Spread Pattern on Outcome of Lumbar Transforaminal Epidural Steroid Injections. Ai Mukai, MD (David Geffen School of Medicine, University of California, Los Angeles, CA); Howard Dedes, MD; David E. Fish, MD, MPH. Disclosure: H. Dedes, none; D.E. Fish, none; A. Mukai, none. Objective: To determine if medication delivery into epidural space confirmed by contrast enhancement fluoroscopic images is superior to a neurogram placement; to determine if lumbar transforaminal epidural steroid injections needle position can effect contrast spread pattern and outcome. Design: Prospective, evaluator-blind clinical trial. Setting: Outpatient multidisciplinary spine care center. Participants: 50 patients with L4 and/or L5 radiculopathy who failed conservative management. Interventions: L4-L5 and/or L5-S1 lumbar transforaminal epidural steroid injections. Main Outcome Measures: A survey that included Verbal Rating Scale (VRS), visual analog scale (VAS), Oswestry Disability Index (ODI), Hospital Anxiety and Depression Scale (HADS), and Pain Catastrophizing Scale (PCS). Fluoroscopic radiographs reviewed by a radiologist blinded to the patient and outcome to identify needle position (AP/lateral views) and contrast flow. With the AP view, the radiologist determined the needle point to be at medial or lateral by using the 6 o’clock position as midline. In the lateral view, the location of the needle tip was classified as 12 o’clock, 3 o’clock, 6 o’clock, or 9 o’clock position. Results: 68% of patients were women and 32% were men, with average age ⫾ SD of 56.7⫾14.9 years (range, 19 – 86y). At the L4-L5 level, 58% were neurograms, 0% epidural only, and 26% with both patterns. At the L5-S1 level, 48% were neurograms, 6% epidural, and 44% had both patterns. There were no statistically significant differences between needle position and functional outcome using the VRS, VAS, and ODI. There appeared to be a trend for better outcome as measured by change in VRS, VAS, HADS, and ODI for epidural contrast pattern. Interestingly, there was a trend for worse PCS scores in the epidural group when compared with the neurogram-only group. Conclusions: These findings suggest that there is no benefit in functional outcome as related to needle position within the foramina. It is likely that regardless of needle position, epidural spread of the medication is the more important factor in functional improvement with lumbar transforaminal epidural steroid injections. Limitations include small sample size and possible overlapping effect with multi-level injections. Further studies with larger sample size are needed to address outcome improvement in correlation with fluoroscopic images. Key Words: Injections; Radiculopathy; Rehabilitation. Poster 267 The Incidence of Intravascular Needle Placement While Performing Medial Branch Nerve Blocks in the Lumbar Spine. Benjamin R. Humpherys, DO (Southwest Spine & Sport, Scottsdale, AZ); Jonathon C. Komar, MD; Anthony A. Lee, MD; Michael J. Simek, MD; Michael W. Wolff, MD. Disclosure: B.R. Humpherys, none; J.C. Komar, none; A.A. Lee, none; M.J. Simek, none; M.W. Wolff, none. Objective: To record the incidence of intravascular needle placement during fluoroscopically guided, contrast-enhanced, medial branch nerve blocks performed at the zygapophyseal joints in the lumbar spine. Design: A prospective, observational study. Setting: Ambulatory surgery center. Participants: Private practice patients with a chief complaint of axial low back pain, clinical signs, and radiographic findings suggestive of zygapophyseal joint-mediated pain. Interventions: 361 consecutive fluoroscopic-guided nerve blocks of the L2, L3, and L4 medial branch nerves and the L5 dorsal rami were performed using International Spine Intervention Society practice guidelines protocol. Once proper needle placement was established, the presence or absence of intravascular needle-tip placeArch Phys Med Rehabil Vol 89, November 2008
ment was identified by the performing physician while injecting contrast dye through the needle during live fluoroscopy. Main Outcome Measures: The lumbar level and side-specific presence of vascular flow of contrast injected under live fluoroscopy. Results: In 361 lumbar medial branch nerve blocks, the overall rate of intravascular needle placement was 13.6%. The level with the highest incidence was L4 (18.2%). The level with the lowest incidence was L5 (6.0%). There was no significant side-to-side difference at each respective lumbar nerve level. Conclusions: There is a significant incidence of intravascular needle placement using standard medial branch nerve block techniques, especially at the L4 medial branch nerve level. Performing medial branch nerve blocks without fluoroscopic confirmation of contrast flow may lead to intravascular administration of medication and may therefore potentially lead to an increase in false negative results and/or potential health risks to patients undergoing these procedures. Key Words: Low back pain; Rehabilitation; Zygapophyseal joint. Poster 268 The Role of Cervical C1/2, C2/3 Spinal Injections in the Diagnosis of Cervicogenic Headache. Linqiu Zhou, MD (Thomas Jefferson University, Philadelphia, PA); Ronnen Abramov, DO; Avi Ashkenazi, MD. Disclosure: R. Abramov, none; A. Ashkenazi, Merck Inc, research grants; L. Zhou, none. Objective: The diagnosis and treatment of cervicogenic headache (CEH) is challenging. This study was to determine the role of C1-C2 and C2-C3 facet joint and dorsal ramus injections in diagnosis of CEH. Design: Retrospective study. Setting: Academic pain center. Participants: 30 patients with clinical diagnosis of CEH, 13 men and 17 women; mean age of 42 years (range, 18 – 65y). All patients had failed multiple pharmacologic and other treatments prior to the study. Average disease duration was 6.9 (0.5–20) years. 10 patients had a unilateral headache and 20 had bilateral headache. All patients underwent a cervical magnetic resonance imaging (MRI). In 26 patients, the MRI demonstrated degenerative disk disease or a herniated disk, most commonly at C5-C6. Interventions: All patients underwent fluoroscopic-guided C1-C2, C2-C3 facet joint injections and C2-C3 dorsal ramus injections. Main Outcome Measures: Numerical pain scale, duration of pain relief (days). Results: 27 out of 30 (90%) patients experienced greater than 50% headache relief, with an average duration of 26 (2–90) days from the first injection. C1-C2 and C2-C3 injections provided a long duration of pain relief. Three patients who did not respond to the injection were finally diagnosed with another type of headache. The response to C1-C2 and C2-C3 injections supports the diagnosis of CEH. Conclusions: C1-C2 and C2-C3 facet joint and dorsal ramus blocks provided significant and prolonged pain relief in the majority of patients in this study. The procedure also plays an important role in diagnosis of CEH. If a patient fails to respond to these injections, another type of headache should be considered. Further randomized studies are needed to compare the sensitivity and specificity of blocking the facet joints versus the dorsal rami in the diagnosis of patients with CEH. Additionally, studies are needed to assess the sensitivity and specificity of the diagnosis in a controlled manner. Key Words: Rehabilitation; Spinal injection. Poster 269 Titration of Oxymorphone Extended Release in Opioid-Experienced Patients With Chronic Low Back Pain Due to a Herniated Disk or Degenerative Disk Disease. Martin E. Hale, MD (Gold Coast Research, LLC, Weston, FL); Harry Ahdieh, PhD; Rosemary Kerwin, PharmD; Tina Ma, PhD. Disclosure: H. Ahdieh, Endo Pharmaceuticals, employment; M.E. Hale, Endo Pharmaceuticals, Inc, research grants; R. Kerwin, Endo