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Lam KHS, Hung CY, Wu TJ. Ultrasound-guided L5/S1 intradiscal needle placement using biplanar approach with the patient in the lateral decubitus position: A report of three cases. Pain Pract 2021; 22:117-122. [PMID: 33949082 DOI: 10.1111/papr.13027] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Revised: 04/24/2021] [Accepted: 04/28/2021] [Indexed: 12/19/2022]
Abstract
BACKGROUND The use of ultrasound (US)-guided intradiscal injection has been described in the literature with the patient lying in the prone position; however, many patients are unable to lie in the prone position. Therefore, we describe an innovative technique of US-guided platelet-rich plasma (PRP) administration in the lumbar intervertebral disc (IVD) of 3 patients with chronic lower back pain who failed to improve with conservative management. CASE SERIES For all the 3 patients, magnetic resonance imaging showed annular tears of the L5/S1 IVD with broad-based central posterior protrusions. PRP injection was performed with the patients in the lateral decubitus position or modified recovery position. With the transducer initially placed in the short axis to the lumbar spine, the needle was inserted in-plane to the IVD, with the needle trajectory clearly visualized. Once the needle entered the annulus fibrosus, placement of the needle was confirmed by turning the transducer along the long axis of the spine to validate the location of the needle tip inside the IVD. Discus stimulation was performed with contrast administered to elicit each patient's usual pain, and spread of the contrast was confirmed under fluoroscopy. Upon confirmation of the intradiscal location, 3 ml of PRP was administered. CONCLUSIONS This report described a novel technique demonstrating that US-guided lumbar intradiscal needle placement for PRP administration in patients lying in the lateral decubitus position is feasible.
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Affiliation(s)
- King Hei Stanley Lam
- The Hong Kong Institute of Musculoskeletal Medicine, Hong Kong, Hong Kong.,Department of Family Medicine, The Chinese University of Hong Kong, Hong Kong, Hong Kong.,Department of Family Medicine, The University of Hong Kong, Hong Kong, Hong Kong
| | - Chen-Yu Hung
- Department of Physical Medicine and Rehabilitation, National Taiwan University Hospital, Taipei, Taiwan
| | - Tsung-Ju Wu
- Graduate Institute of Basic Medical Science, China Medical University, Taichung, Taiwan.,Department of Physical Medicine and Rehabilitation, Yuanlin Christian Hospital, Changhua, Taiwan
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Centeno C, Markle J, Dodson E, Stemper I, Williams CJ, Hyzy M, Ichim T, Freeman M. Treatment of lumbar degenerative disc disease-associated radicular pain with culture-expanded autologous mesenchymal stem cells: a pilot study on safety and efficacy. J Transl Med 2017; 15:197. [PMID: 28938891 PMCID: PMC5610473 DOI: 10.1186/s12967-017-1300-y] [Citation(s) in RCA: 76] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2017] [Accepted: 09/14/2017] [Indexed: 12/17/2022] Open
Abstract
Background Degenerative disc disease (DDD) is a common cause of lower back pain with radicular symptoms and has a significant socioeconomic impact given the associated disability. Limited effective conservative therapeutic options result in many turning to surgical alternatives for management, which vary in the rate of success and also carry an increased risk of morbidity and mortality associated with the procedures. Several animal based studies and a few human pilot studies have demonstrated safety and suggest efficacy in the treatment of DDD with mesenchymal stem cells (MSCs). The use of bone marrow-derived MSCs for the treatment of DDD is promising and in the present study we report on the safety and efficacy findings from a registry based proof of concept study using a percutaneous intradiscal injection of cultured MSCs for the management of DDD with associated radicular symptoms. Methods Thirty-three patients with lower back pain and disc degeneration with a posterior disc bulge diagnosed on magnetic resonance imaging (MRI) met the inclusion criteria and were treated with culture-expanded, autologous, bone marrow-derived MSCs. Prospective registry data was obtained at multiple time intervals up to 6 years post-treatment. Collected outcomes included numeric pain score (NPS), a modified single assessment numeric evaluation (SANE) rating, functional rating index (FRI), measurement of the intervertebral disc posterior dimension, and adverse events. Results Three patients reported pain related to procedure that resolved. There were no serious adverse events (i.e. death, infection, or tumor) associated with the procedure. NPS change scores relative to baseline were significant at 3, 36, 48, 60, and 72 months post-treatment. The average modified SANE ratings showed a mean improvement of 60% at 3 years post-treatment. FRI post-treatment change score averages exceeded the minimal clinically important difference at all time points except 12 months. Twenty of the patients treated underwent post-treatment MRI and 85% had a reduction in disc bulge size, with an average reduction size of 23% post-treatment. Conclusions Patients treated with autologous cultured MSCs for lower back pain with radicular symptoms in the setting of DDD reported minor adverse events and significant improvements in pain, function, and overall subjective improvement through 6 years of follow-up. NCT03011398. A Clinical Registry of Orthobiologics Procedures. https://clinicaltrials.gov/ct2/show/NCT03011398?term=orthobiologics&rank=1
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Affiliation(s)
- Christopher Centeno
- Centeno-Schultz Clinic, Broomfield, CO, 80021, USA.,Regenerative Sciences, LLC, 403 Summit Blvd Suite 201, Broomfield, CO, 80021, USA
| | - Jason Markle
- Centeno-Schultz Clinic, Broomfield, CO, 80021, USA
| | - Ehren Dodson
- Regenerative Sciences, LLC, 403 Summit Blvd Suite 201, Broomfield, CO, 80021, USA.
| | - Ian Stemper
- Regenerative Sciences, LLC, 403 Summit Blvd Suite 201, Broomfield, CO, 80021, USA
| | | | - Matthew Hyzy
- Centeno-Schultz Clinic, Broomfield, CO, 80021, USA
| | | | - Michael Freeman
- CAPHRI School of Public Health and Primary Care, Maastricht University, Maastricht, Netherlands
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Jha SC, Higashino K, Sakai T, Takata Y, Abe M, Yamashita K, Morimoto M, Fukuta S, Nagamachi A, Sairyo K. Clinical Significance of High-intensity Zone for Discogenic Low Back Pain: A Review. THE JOURNAL OF MEDICAL INVESTIGATION 2017; 63:1-7. [PMID: 27040045 DOI: 10.2152/jmi.63.1] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
High-intensity zone (HIZ) was originally described as a high-intensity signal on T2-weighted magnetic resonance (MR) images, located in the posterior annulus fibrosus, clearly separated from the nucleus pulposus. Among symptomatic patients with low back pain, HIZ is present in 28-59% of cases. In morphologically abnormal discs, high sensitivity and specificity of 81% and 79%, respectively, were reported for HIZs and concordant pain during discography. In contrast, another report indicated low rates. Although most papers reported high sensitivity and specificity for this relationship, it remains controversial. Regarding the pathology of HIZs, inflammatory granulation tissues are found at sites showing HIZs. Such inflammatory tissues produce pro-inflammatory cytokines and mediators, which sensitize the nociceptors within the disc and cause pain. An effective treatment for this condition is yet to be established. Recently, minimally invasive surgery using percutaneous endoscopic discectomy (PED) under local anesthesia was introduced. After removal of the degenerated disc material, the HIZ is identified with the endoscope and then coagulated and modulated with a bipolar radio pulse. This technique is called thermal annuloplasty. In conclusion, HIZs is an important sign of painful intervertebral disc disruption, if identified precisely based on factors such as location and intensity.
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Sainoh T, Orita S, Miyagi M, Inoue G, Kamoda H, Ishikawa T, Yamauchi K, Suzuki M, Sakuma Y, Kubota G, Oikawa Y, Inage K, Sato J, Nakata Y, Nakamura J, Aoki Y, Toyone T, Takahashi K, Ohtori S. Single Intradiscal Administration of the Tumor Necrosis Factor-Alpha Inhibitor, Etanercept, for Patients with Discogenic Low Back Pain. PAIN MEDICINE 2016; 17:40-5. [PMID: 26243249 DOI: 10.1111/pme.12892] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
OBJECTIVE To examine the analgesic effect of intradiscal administration of a tumor necrosis factor-αα (TNF-α) inhibitor in patients with discogenic low back pain (LBP). DESIGN Prospective, randomized study. SETTING Department of Orthopaedic Surgery, Chiba (Japan) University Hospital. SUBJECTS Seventy-seven patients diagnosed with discogenic LBP. METHODS Discogenic LBP patients were randomly assigned to the etanercept (n = 38; bupivacaine [2 mL] with etanercept [10 mg]) or control (n = 39; bupivacaine [2 mL]) groups. Patients received a single intradiscal injection. Numerical rating scale (NRS) scores for LBP at baseline, 1 day, and 1, 2, 4, and 8 weeks after the injection were recorded. The Oswestry disability index (ODI) scores at baseline and at 4 and 8 weeks after injection were evaluated. Postinjection complications were recorded and evaluated. RESULTS In the etanercept group, the NRS scores were significantly lower than in the control group at every time point after the injection for 8 weeks (P < 0.05). Similarly, 4 weeks after the injection, the ODI score was lower in the etanercept group than in the control group (P < 0.05). However, the ODI scores were not significantly different at 8 weeks. Complications were not observed. CONCLUSIONS Single intradiscal administration of a TNF-α inhibitor can alleviate intractable discogenic LBP for up to 8 weeks. TNF-α may be involved in discogenic pain pathogenesis. This procedure is a novel potential treatment; longer-term effectiveness trials are required in the future.
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Omar EA, Pimentel DC, Amadera JED. Spinal Pathology. PATHOLOGY AND INTERVENTION IN MUSCULOSKELETAL REHABILITATION 2016:561-583. [DOI: 10.1016/b978-0-323-31072-7.00015-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/01/2023]
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Hooten WM, Cohen SP. Evaluation and Treatment of Low Back Pain: A Clinically Focused Review for Primary Care Specialists. Mayo Clin Proc 2015; 90:1699-718. [PMID: 26653300 DOI: 10.1016/j.mayocp.2015.10.009] [Citation(s) in RCA: 72] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2015] [Revised: 10/10/2015] [Accepted: 10/15/2015] [Indexed: 01/15/2023]
Abstract
Low back pain (LBP) is a leading cause of disability worldwide. In the absence of a classification system for pain syndromes, classification of LBP on the basis of the distribution of pain as axial (pain generally localized to the low back) or radicular neuropathic (pain radiating to the lower extremities) is relevant to clinical practice because the distribution of pain is often a corollary of frequently occurring disease processes involving the lumbar spine. Common sources of axial LBP include the intervertebral disc, facet joint, sacroiliac joint, and paraspinal musculature, whereas common sources of radicular pain include a herniated intervertebral disc and spinal stenosis. The accuracy of historical and physical examination findings has been established for sacroiliac joint pain, radiculopathy, and lumbar spinal stenosis. However, the accuracy of similar data, so-called red flags, for identifying the underlying medical sources of LBP has been overstated. Diagnostic imaging studies can be useful, and adherence to established guidelines can protect against overuse. Multiple pharmacological trials exist for the management of LBP; however, the long-term outcomes of commonly used drugs are mixed. For carefully selected patients with axial LBP, radiofrequency denervation techniques can provide sustained pain relief. In patients with radicular pain, transforaminal epidural steroid injections may provide short-term pain relief, but neurostimulation may confer more enduring benefits of refractory symptoms. Pain-related indications for commonly performed operations include spinal decompression for radicular symptoms as well as spinal fusion or disc prosthesis for discogenic LBP. Physical modalities and psychological treatments can improve pain and functioning, but patient preferences may influence treatment adherence.
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Affiliation(s)
- W Michael Hooten
- Mayo Clinic College of Medicine and Department of Anesthesiology, Division of Pain Medicine, Mayo Clinic, Rochester, MN.
| | - Steven P Cohen
- Department of Anesthesiology and Critical Care Medicine, Department of Physical Medicine and Rehabilitation, Johns Hopkins School of Medicine, Baltimore, MD; Department of Anesthesiology, Department of Physical Medicine and Rehabilitation, Uniformed Services University of Health Sciences, Bethesda, MD
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Khan I, Hargunani R, Saifuddin A. The lumbar high-intensity zone: 20 years on. Clin Radiol 2014; 69:551-8. [PMID: 24613582 DOI: 10.1016/j.crad.2013.12.012] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2013] [Revised: 11/23/2013] [Accepted: 12/16/2013] [Indexed: 10/25/2022]
Abstract
The high intensity zone (HIZ) was first described by Aprill and Bogduk on lumbar spine magnetic resonance imaging (MRI) studies in 1992. Correlation with lumbar computed tomography (CT) discography showed that the HIZ represents a deep radial tear of the annulus fibrosus, which may be a cause of chronic low back pain. Initial studies comparing the finding of a HIZ on MRI with discography suggested that it may be a highly specific marker of a painful lumbar disc, but later investigators demonstrated that it is also present in asymptomatic individuals. The purpose of this article is to review the literature regarding the lumbar HIZ 20 years after its initial description.
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Affiliation(s)
- I Khan
- Department of Radiology, Royal National Orthopaedic Hospital, Stanmore, Middlesex, UK.
| | - R Hargunani
- Department of Radiology, Royal National Orthopaedic Hospital, Stanmore, Middlesex, UK
| | - A Saifuddin
- Department of Radiology, Royal National Orthopaedic Hospital, Stanmore, Middlesex, UK
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Hussain A, Erdek M. Interventional Pain Management for Failed Back Surgery Syndrome. Pain Pract 2013; 14:64-78. [DOI: 10.1111/papr.12035] [Citation(s) in RCA: 77] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2012] [Accepted: 12/02/2012] [Indexed: 11/28/2022]
Affiliation(s)
- Arif Hussain
- Department of Physical Medicine and Rehabilitation; School of Medicine; Johns Hopkins University; Baltimore Maryland U.S.A
| | - Michael Erdek
- Division of Pain Medicine; Department of Anesthesia and Critical Care Medicine; School of Medicine; Johns Hopkins University; Baltimore Maryland U.S.A
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Ethical challenges and interventional pain medicine. Curr Pain Headache Rep 2012; 16:1-8. [PMID: 22160519 DOI: 10.1007/s11916-011-0242-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
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