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Poster 310 Efficacy of Transforaminal Epidural Steroid Injection in the Treatment of Lumbosacral Radicular Pain in the Obese, Overweight, and Nonoverweight Populations
PM&R
the presence of blood during any moment of the procedure, either by visualization of blood reflux in the hub of the needle; aspiration or by blood vessel visualization under live fluoroscopy with contrast injection (OR, 7.92 [95% CI, 1.97-31.82]). The chance of vascular penetration was greater in sacral procedures compared with cervical procedures (OR, 3.34 [95% CI, 1.35-8.31]) and with lumbar procedures (OR, 4.57 [95% CI, 2.26-9.27]). Conclusions: Perineal pruritus that occurs as a result of TFESI with dexamethasone injection represents a relatively rare but distinct transient adverse effect. In our study, the incidence of perineal pruritus was associated with detection of a vascular penetration during the needle insertion process and mainly with the visualization of a blood vessel during injection of contrast under live fluoroscopy or digital subtraction. The probability of perineal pruritus was greater in sacral injections compared with lumbar injections.
Poster 308 Body Mass Index and Treatment Response to the Brief Interdisciplinary Fibromyalgia Treatment Program in Patients With Fibromyalgia. Terry H. Oh, MD (Mayo Clinic, Rochester, MN, United States); Chul Hyun Kim, Connie Luedtke, MA, RN, BC, Ann Vincent, MBBS, MD. Disclosures: T. H. Oh, none. Objective: To evaluate the influence of body mass index (BMI) on treatment outcome in patients with fibromyalgia. Design: A retrospective longitudinal cohort study. Setting: Fibromyalgia treatment program (FTP) at a tertiary medical center. Participants: A total of 477 patients with fibromyalgia who completed the Fibromyalgia Impact Questionnaire (FIQ) and the Short Form 36 Health Status Questionnaire (SF-36) at baseline and 6-12 months after the FTP. Interventions: An 1.5-day interdisciplinary FTP, including pretreatment measurements, education, self-management, and physical and occupational therapy sessions. Main Outcome Measures: Improvement on the FIQ and SF-36 scores between baseline and 6-12 months follow-up. Results: Patients who were nonobese (BMI ⬍25), overweight (BMI, 25-29.9), obese (BMI, 30-34.9), and severely obese (BMIⱖ35) were 30% (143), 30% (142), 22% (107) and 18% (85), respectively. Overall, each of the 4 BMI groups observed significant improvements (P⬍.05) between baseline and follow-up for the FIQ total score, for several of the FIQ subscales, including feel good, job ability, pain, fatigue, and morning tiredness, and for the SF-36 subscales, including pain index, vitality, social functioning, and mental health index. The magnitude of baseline to follow-up change did not differ significantly across the 4 BMI groups for the majority of scores after adjusting for age and baseline score. The only significant differences identified across the 4 BMI groups were for the SF-36 subscale scores of physical functioning (P⫽.03) and roleemotional (P⫽.04), with the trend of less improvement for those with higher BMI. Conclusions: Baseline BMI status does not appear to affect treatment response to FTP as measured by the FIQ or SF-36 physical and mental component summary scores. However, the SF-36 subscales of physical functioning and role emotional showed a significant trend toward less improvement for those with higher BMI.
Vol. 3, Iss. 10S1, 2011
S279
Poster 309 Race and Ethnicity in the Prescription of Opiate Pain Medications for Back Pain in the Emergency Departments of the United States, 1997-2008. Ming-Chih J. Kao, PhD, MD (Stanford University, Los Altos, CA, United States); Salar Deldar, MD, Grace Y. Huang, MD, Raj Mitra, MD. Disclosures: M. J. Kao, none. Objective: Racial and ethnic discrepancies in prescription opiate medications (POM) used in emergency departments (ED) are well known. We study the trend in the role of race in POM for moderateto-severe low back pain (MS-LBP) in ED visits. Design: National Hospital and Ambulatory Medical Center Survey was obtained from the NCHS. ED data 1997-2000 and 20022008 were investigated. In 2001-2002, pain severity was not collected. SAS 9.2 and R were used for analysis. Masked “ultimate cluster” weights and domain analysis were used. Rates of POM adjusted for age and gender were estimated by weighted multivariate logistic regression. Trend was estimated by weighted least squares regression. Setting: National multistage probability survey of EDs in the United States. Participants: Patients at selected health care facilities. Interventions: N/A. Main Outcome Measures: Proportions, by race, of ED visits with chief complaint of MS-LBP leading to POM. Results: 309,029 visits from 1997-2008 (sans 2001-2002) were analyzed, which represented 1.11B ED visits at all nonfederal health care facilities in the United States. Of these, 2153 and 1142 visits were MS-LBP visits made by African Americans and Hispanic Americans, respectively. Estimates presented are adjusted for age and gender. In ED visits for MS-LBP, compared with Caucasians, African Americans were much less likely to receive POM (odds ratio [OR], 0.49 [95% confidence interval {CI}, 0.34-0.70]) in 1997-2000. Over time, this progressively attenuated in 2003-2004 (OR, 0.52 [95% CI, 0.41-0.68]), and 2005-2006 (OR, 0.72 [955 CI, 0.550.96]). In 2007-2008, this decreased to 1997-2000 levels (OR, 0.57 [95% CI, 0.46-0.72]). Hispanic Americans also were less likely to receive POM for MS-LBP (OR, 0.63 [95% CI, 0.41-0.96]). This steadily increased through 2003-2004 (OR, 0.66 [95% CI, 0.470.92]) and 2005-2006 (OR, 0.67 [95% CI, 0.48-0.92]). In 20072008, there was no statistically significant difference for Hispanic Americans compared with Caucasians (OR, 0.79 [95% CI, 0.601.04]). Due to the limited number of periods, this increase was not statistically significant in either regression or bivariate comparisons. Conclusions: From 1997-2008, both African American and Hispanic American patients who presented to the ED with MS-LBP were less likely than Caucasians to receive POMs. However, for Hispanic Americans this discrepancy has shown progressive attenuation.
Poster 310 Efficacy of Transforaminal Epidural Steroid Injection in the Treatment of Lumbosacral Radicular Pain in the Obese, Overweight, and Nonoverweight Populations. Zachary McCormick, MD (University of Pennsylvania, Philadelphia, PA, United States); Chris Plastaras, MD. Disclosures: Z. McCormick, none.
S280
Objective: To determine if lumbosacral transforaminal epidural steroid injection (LTFESI) is as effective in treating lumbosacral radicular pain in obese (body mass index [BMI] ⬎30) and overweight (25⬍BMI⬍30) population compared with the nonoverweight (18.5⬍BMI⬍25) population, because BMI has not been described as a prognostic indicator with regard to LTFESI outcomes. Design: Retrospective, case control pilot study. Setting: Major metropolitan urban academic spine and sports clinic. Participants: Patients who were not overweight (n⫽9), overweight (n⫽9), and obese (n⫽6) presented with lumbosacral radicular pain and received a LTFESI. Interventions: Fluoroscopically guided contrast-enhanced LTFESI. Main Outcome Measures: 11-point pain intensity numeric rating scale scores were recorded before LTFESI and at an average follow-up interval of 4 weeks. We determined the mean percentage reduction in pain and the proportion of individuals with a 50% or greater reduction in pain in the 3 BMI groups. Results: No significant differences were found between the normal BMI group and higher BMI groups with regard to percentage improvement in pain (P⫽.7154, P⫽.4566) or in the proportion of each group with a 50% or greater reduction in pain (P⫽.4566, P⫽.1520). Conclusions: This preliminary data does not show that LTFESI is less effective for the higher BMI groups compared with normal BMI cohorts for the treatment of lumbosacral radicular pain. However, our sample size was not large enough to find a significant difference at a power of 80%. A larger study is needed to confirm whether BMI is a prognostic indicator for outcomes of LTFESI for lumbosacral radicular pain.
Poster 311 A Correlative Study of the Self-reported Ratings Determining Impairment Associated With Pain, From the AMA Guides 5th Edition, and the Clinician-derived Physical Performance Tests on Individuals With Polytrauma History and With Chronic Pain: Case Series. Armando S. Miciano, MD (Nevada Rehabilitation Institute, Las Vegas, NV, United States); Jacqueline Derhousoff, Chad Cross, PhD. Disclosures: A. S. Miciano, none. Objective: To quantify pain-related impairments (PRI) of individuals with Polytrauma history ⬎2 years and chronic nonmalignant pain (CNP) by using the self-reported Ratings Determining Impairment Associated with Pain (RDIP), obtained from the AMA Guides 5th Edition and to investigate the correlation between PRI and clinician-derived Physical Performance Test (PPT) scores. Design: Retrospective cross-sectional study. Setting: Medicare-accredited Comprehensive Outpatient Rehabilitation Facility (CORF). Participants: 33 participants with polytrauma reporting CNP (ages, 22-78 years). Interventions: None. Main Outcome Measures: The Self-Administered Co-Morbidity Questionnaire identified individuals afflicted with CNP. The RDIP identified PRI via 5 subscales: Pain Severity; Activity Interfer-
PRESENTATIONS
ence; Mood Effect; Global Pain Behavior; and, Credibility; it was categorized as: no PRI (0-6), mild (7-24), moderate (25-42), moderately severe (43-60), and severe PRI (61-80). The PPTs were 6-Minute Walk (6MWT), Berg Balance Scale (BBS), and Dynamic Gait Index (DGI). Pearson correlation coefficients (r) examined associations between RDIP and PPT. An ␣ of .10 was used for statistical tests. Results: Total RDIP resulted in 0% mild PRI, 21% moderate, 33.33% moderately severe, and 45.45% severe PRI. Neither age (F⫽1.619, P⫽.168) nor gender (F⫽0.717, P⫽.710) were significant factors. A statistically significant negative correlation was found between total RDIP versus BBS (r ⫽ –.480, P⫽.005), DGI (r ⫽ –.573, P⬍.001), 6MWT distance (r ⫽ –.506, P⫽.003), and 6MWT Metabolic Equivalents (r ⫽ –.511, P⫽.002). Conclusions: The majority scored in moderately severe to severe PRI categories. The PRI severity had statistically significant negative effects on PPT scores. These findings suggest that the self-reported RDIP is a reliable indicator of physical performance and valuable as an alternative to PPT in a busy clinical practice.
Poster 312 Efficacy of Combined Intra-articular Facet Joint and Transforaminal Epidural Steroid Injection in the Management of Symptomatic Lumbosacral Lateral Recess Stenosis: A Retrospective Analysis. Michael J. Louwers, MD (University of Michigan, Ann Arbor, MI, United States); Anthony E. Chiodo, MD, Jared S. Greenberg, MD, Kori Rothman, DO. Disclosures: M. J. Louwers, none. Objective: The purpose of this study is to evaluate the efficacy of combining a transforaminal epidural steroid injection (TFESI) with intra-articular facet injection to improve pain and functional outcomes. We hypothesize a synergistic effect on reduction of pain and dysfunction when using this interventional approach, because lateral recess stenosis is most often caused by facet hypertrophic changes. Design: This is a retrospective analysis of a preexisting data set of 1050 patients. Among inclusion criteria, subjects must have undergone a lumbosacral TFESI for which they completed a pre- and postinjection questionnaire. Our 2 cohorts include those who received lumbosacral TFESI alone and those that received a simultaneous intraarticular facet joint injection at the same level. Cohorts are further categorized based on their severity of lateral recess stenosis. Setting: Tertiary care center. Participants: Preexisting data set from the Spine Program Injections Quality Improvement database at the University of Michigan. Interventions: This is a retrospective review, with no new intervention. Participants in the data set received various spine interventions that were clinically indicated. Main Outcome Measures: The database includes responses to pre- and postinjection questionnaires from patients who received injections at the University of Michigan Spine Center from 20062009. The preinjection data include demographic data, work status, functional activities, and VAS pain scores. The postinjection data include those questions asked in the preinjection questionnaire along with injection satisfaction. Results: To date, we have preliminary data; however, initial review shows promising results for improved pain and functional outcomes when combining transforaminal epidural steroid and intraarticular facet injections for patients with symptomatic lumbosacral radicular pain.
the presence of blood during any moment of the procedure, either by visualization of blood reflux in the hub of the needle; aspiration or by blood vessel visualization under live fluoroscopy with contrast injection (OR, 7.92 [95% CI, 1.97-31.82]). The chance of vascular penetration was greater in sacral procedures compared with cervical procedures (OR, 3.34 [95% CI, 1.35-8.31]) and with lumbar procedures (OR, 4.57 [95% CI, 2.26-9.27]). Conclusions: Perineal pruritus that occurs as a result of TFESI with dexamethasone injection represents a relatively rare but distinct transient adverse effect. In our study, the incidence of perineal pruritus was associated with detection of a vascular penetration during the needle insertion process and mainly with the visualization of a blood vessel during injection of contrast under live fluoroscopy or digital subtraction. The probability of perineal pruritus was greater in sacral injections compared with lumbar injections.
Poster 308 Body Mass Index and Treatment Response to the Brief Interdisciplinary Fibromyalgia Treatment Program in Patients With Fibromyalgia. Terry H. Oh, MD (Mayo Clinic, Rochester, MN, United States); Chul Hyun Kim, Connie Luedtke, MA, RN, BC, Ann Vincent, MBBS, MD. Disclosures: T. H. Oh, none. Objective: To evaluate the influence of body mass index (BMI) on treatment outcome in patients with fibromyalgia. Design: A retrospective longitudinal cohort study. Setting: Fibromyalgia treatment program (FTP) at a tertiary medical center. Participants: A total of 477 patients with fibromyalgia who completed the Fibromyalgia Impact Questionnaire (FIQ) and the Short Form 36 Health Status Questionnaire (SF-36) at baseline and 6-12 months after the FTP. Interventions: An 1.5-day interdisciplinary FTP, including pretreatment measurements, education, self-management, and physical and occupational therapy sessions. Main Outcome Measures: Improvement on the FIQ and SF-36 scores between baseline and 6-12 months follow-up. Results: Patients who were nonobese (BMI ⬍25), overweight (BMI, 25-29.9), obese (BMI, 30-34.9), and severely obese (BMIⱖ35) were 30% (143), 30% (142), 22% (107) and 18% (85), respectively. Overall, each of the 4 BMI groups observed significant improvements (P⬍.05) between baseline and follow-up for the FIQ total score, for several of the FIQ subscales, including feel good, job ability, pain, fatigue, and morning tiredness, and for the SF-36 subscales, including pain index, vitality, social functioning, and mental health index. The magnitude of baseline to follow-up change did not differ significantly across the 4 BMI groups for the majority of scores after adjusting for age and baseline score. The only significant differences identified across the 4 BMI groups were for the SF-36 subscale scores of physical functioning (P⫽.03) and roleemotional (P⫽.04), with the trend of less improvement for those with higher BMI. Conclusions: Baseline BMI status does not appear to affect treatment response to FTP as measured by the FIQ or SF-36 physical and mental component summary scores. However, the SF-36 subscales of physical functioning and role emotional showed a significant trend toward less improvement for those with higher BMI.
Vol. 3, Iss. 10S1, 2011
S279
Poster 309 Race and Ethnicity in the Prescription of Opiate Pain Medications for Back Pain in the Emergency Departments of the United States, 1997-2008. Ming-Chih J. Kao, PhD, MD (Stanford University, Los Altos, CA, United States); Salar Deldar, MD, Grace Y. Huang, MD, Raj Mitra, MD. Disclosures: M. J. Kao, none. Objective: Racial and ethnic discrepancies in prescription opiate medications (POM) used in emergency departments (ED) are well known. We study the trend in the role of race in POM for moderateto-severe low back pain (MS-LBP) in ED visits. Design: National Hospital and Ambulatory Medical Center Survey was obtained from the NCHS. ED data 1997-2000 and 20022008 were investigated. In 2001-2002, pain severity was not collected. SAS 9.2 and R were used for analysis. Masked “ultimate cluster” weights and domain analysis were used. Rates of POM adjusted for age and gender were estimated by weighted multivariate logistic regression. Trend was estimated by weighted least squares regression. Setting: National multistage probability survey of EDs in the United States. Participants: Patients at selected health care facilities. Interventions: N/A. Main Outcome Measures: Proportions, by race, of ED visits with chief complaint of MS-LBP leading to POM. Results: 309,029 visits from 1997-2008 (sans 2001-2002) were analyzed, which represented 1.11B ED visits at all nonfederal health care facilities in the United States. Of these, 2153 and 1142 visits were MS-LBP visits made by African Americans and Hispanic Americans, respectively. Estimates presented are adjusted for age and gender. In ED visits for MS-LBP, compared with Caucasians, African Americans were much less likely to receive POM (odds ratio [OR], 0.49 [95% confidence interval {CI}, 0.34-0.70]) in 1997-2000. Over time, this progressively attenuated in 2003-2004 (OR, 0.52 [95% CI, 0.41-0.68]), and 2005-2006 (OR, 0.72 [955 CI, 0.550.96]). In 2007-2008, this decreased to 1997-2000 levels (OR, 0.57 [95% CI, 0.46-0.72]). Hispanic Americans also were less likely to receive POM for MS-LBP (OR, 0.63 [95% CI, 0.41-0.96]). This steadily increased through 2003-2004 (OR, 0.66 [95% CI, 0.470.92]) and 2005-2006 (OR, 0.67 [95% CI, 0.48-0.92]). In 20072008, there was no statistically significant difference for Hispanic Americans compared with Caucasians (OR, 0.79 [95% CI, 0.601.04]). Due to the limited number of periods, this increase was not statistically significant in either regression or bivariate comparisons. Conclusions: From 1997-2008, both African American and Hispanic American patients who presented to the ED with MS-LBP were less likely than Caucasians to receive POMs. However, for Hispanic Americans this discrepancy has shown progressive attenuation.
Poster 310 Efficacy of Transforaminal Epidural Steroid Injection in the Treatment of Lumbosacral Radicular Pain in the Obese, Overweight, and Nonoverweight Populations. Zachary McCormick, MD (University of Pennsylvania, Philadelphia, PA, United States); Chris Plastaras, MD. Disclosures: Z. McCormick, none.
S280
Objective: To determine if lumbosacral transforaminal epidural steroid injection (LTFESI) is as effective in treating lumbosacral radicular pain in obese (body mass index [BMI] ⬎30) and overweight (25⬍BMI⬍30) population compared with the nonoverweight (18.5⬍BMI⬍25) population, because BMI has not been described as a prognostic indicator with regard to LTFESI outcomes. Design: Retrospective, case control pilot study. Setting: Major metropolitan urban academic spine and sports clinic. Participants: Patients who were not overweight (n⫽9), overweight (n⫽9), and obese (n⫽6) presented with lumbosacral radicular pain and received a LTFESI. Interventions: Fluoroscopically guided contrast-enhanced LTFESI. Main Outcome Measures: 11-point pain intensity numeric rating scale scores were recorded before LTFESI and at an average follow-up interval of 4 weeks. We determined the mean percentage reduction in pain and the proportion of individuals with a 50% or greater reduction in pain in the 3 BMI groups. Results: No significant differences were found between the normal BMI group and higher BMI groups with regard to percentage improvement in pain (P⫽.7154, P⫽.4566) or in the proportion of each group with a 50% or greater reduction in pain (P⫽.4566, P⫽.1520). Conclusions: This preliminary data does not show that LTFESI is less effective for the higher BMI groups compared with normal BMI cohorts for the treatment of lumbosacral radicular pain. However, our sample size was not large enough to find a significant difference at a power of 80%. A larger study is needed to confirm whether BMI is a prognostic indicator for outcomes of LTFESI for lumbosacral radicular pain.
Poster 311 A Correlative Study of the Self-reported Ratings Determining Impairment Associated With Pain, From the AMA Guides 5th Edition, and the Clinician-derived Physical Performance Tests on Individuals With Polytrauma History and With Chronic Pain: Case Series. Armando S. Miciano, MD (Nevada Rehabilitation Institute, Las Vegas, NV, United States); Jacqueline Derhousoff, Chad Cross, PhD. Disclosures: A. S. Miciano, none. Objective: To quantify pain-related impairments (PRI) of individuals with Polytrauma history ⬎2 years and chronic nonmalignant pain (CNP) by using the self-reported Ratings Determining Impairment Associated with Pain (RDIP), obtained from the AMA Guides 5th Edition and to investigate the correlation between PRI and clinician-derived Physical Performance Test (PPT) scores. Design: Retrospective cross-sectional study. Setting: Medicare-accredited Comprehensive Outpatient Rehabilitation Facility (CORF). Participants: 33 participants with polytrauma reporting CNP (ages, 22-78 years). Interventions: None. Main Outcome Measures: The Self-Administered Co-Morbidity Questionnaire identified individuals afflicted with CNP. The RDIP identified PRI via 5 subscales: Pain Severity; Activity Interfer-
PRESENTATIONS
ence; Mood Effect; Global Pain Behavior; and, Credibility; it was categorized as: no PRI (0-6), mild (7-24), moderate (25-42), moderately severe (43-60), and severe PRI (61-80). The PPTs were 6-Minute Walk (6MWT), Berg Balance Scale (BBS), and Dynamic Gait Index (DGI). Pearson correlation coefficients (r) examined associations between RDIP and PPT. An ␣ of .10 was used for statistical tests. Results: Total RDIP resulted in 0% mild PRI, 21% moderate, 33.33% moderately severe, and 45.45% severe PRI. Neither age (F⫽1.619, P⫽.168) nor gender (F⫽0.717, P⫽.710) were significant factors. A statistically significant negative correlation was found between total RDIP versus BBS (r ⫽ –.480, P⫽.005), DGI (r ⫽ –.573, P⬍.001), 6MWT distance (r ⫽ –.506, P⫽.003), and 6MWT Metabolic Equivalents (r ⫽ –.511, P⫽.002). Conclusions: The majority scored in moderately severe to severe PRI categories. The PRI severity had statistically significant negative effects on PPT scores. These findings suggest that the self-reported RDIP is a reliable indicator of physical performance and valuable as an alternative to PPT in a busy clinical practice.
Poster 312 Efficacy of Combined Intra-articular Facet Joint and Transforaminal Epidural Steroid Injection in the Management of Symptomatic Lumbosacral Lateral Recess Stenosis: A Retrospective Analysis. Michael J. Louwers, MD (University of Michigan, Ann Arbor, MI, United States); Anthony E. Chiodo, MD, Jared S. Greenberg, MD, Kori Rothman, DO. Disclosures: M. J. Louwers, none. Objective: The purpose of this study is to evaluate the efficacy of combining a transforaminal epidural steroid injection (TFESI) with intra-articular facet injection to improve pain and functional outcomes. We hypothesize a synergistic effect on reduction of pain and dysfunction when using this interventional approach, because lateral recess stenosis is most often caused by facet hypertrophic changes. Design: This is a retrospective analysis of a preexisting data set of 1050 patients. Among inclusion criteria, subjects must have undergone a lumbosacral TFESI for which they completed a pre- and postinjection questionnaire. Our 2 cohorts include those who received lumbosacral TFESI alone and those that received a simultaneous intraarticular facet joint injection at the same level. Cohorts are further categorized based on their severity of lateral recess stenosis. Setting: Tertiary care center. Participants: Preexisting data set from the Spine Program Injections Quality Improvement database at the University of Michigan. Interventions: This is a retrospective review, with no new intervention. Participants in the data set received various spine interventions that were clinically indicated. Main Outcome Measures: The database includes responses to pre- and postinjection questionnaires from patients who received injections at the University of Michigan Spine Center from 20062009. The preinjection data include demographic data, work status, functional activities, and VAS pain scores. The postinjection data include those questions asked in the preinjection questionnaire along with injection satisfaction. Results: To date, we have preliminary data; however, initial review shows promising results for improved pain and functional outcomes when combining transforaminal epidural steroid and intraarticular facet injections for patients with symptomatic lumbosacral radicular pain.