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Ab Aziz SNF, Zakaria Mohamad Z, Karupiah RK, Che Ahmad A, Omar AS. Efficacy of Sacroiliac Joint Injection With Anesthetic and Corticosteroid: A Prospective Observational Study. Cureus 2022; 14:e24039. [PMID: 35547453 PMCID: PMC9090203 DOI: 10.7759/cureus.24039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/10/2022] [Indexed: 11/25/2022] Open
Abstract
Sacroiliac joint injection aims to provide pain relief, improve work status, and early return to work. We aimed to investigate the role of corticosteroid and anesthetic mixture to provide short- and long-term pain relief in patients with sacroiliac joint pain. This prospective observational study included 27 patients with sacroiliac joint dysfunction who received a combination of triamcinolone and ropivacaine for sacroiliac joint injection followed by three scheduled visits at four weeks, eight weeks, and six months. The pain was assessed using visual analogue scale (VAS), physician's assessment on the number of positive provocative tests, and patients' self-reported assessment to evaluate their functional outcome. At the four weeks and eight weeks follow up evaluations, the mean VAS reduced from 5.85 (±1.03) at baseline to 3.30 (±1.77) at four weeks, 3.30 (±1.86) at eight weeks, and 3.00 (±1.86) at six months. At each interval, improvement in terms of clinical assessment using a series of provocative tests was seen with a mean of 1.37 (±1.33), 1.63 (±1.31), and 1.48 (±1.05) at four weeks, eight weeks, and six months, respectively. For the functional effectiveness parameters (Roland-Morris questionnaires), the sacroiliac joint (SIJ) injected with these drugs combination showed a more significant improvement in symptoms and function, baseline (13.56±3.36), at four weeks (9.04±3.33), at eight weeks (9.07±4.13), and six months (8.26±4.92). Using the one-way repeated measures ANOVA, the SIJ pain, provocative test, and functional outcome significantly improved over time after injection with triamcinolone and ropivacaine (p<0.001). No complications of the administration of these medications were noted. Our findings support the intermediate-term (six months) effectiveness and safety of a combination of corticosteroid and anesthetic injection for patients with SIJ dysfunction who failed conservative treatment.
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Affiliation(s)
| | - Zamzuri Zakaria Mohamad
- Orthopedics, Traumatology and Rehabilitation, International Islamic University Malaysia, Kuantan, MYS
| | - Rajandra Kumar Karupiah
- Orthopedics, Traumatology and Rehabilitation, Kulliyyah of Medicine, International Islamic University Malaysia, Kuantan, MYS
| | - Aminudin Che Ahmad
- Orthopedics, Sultan Ahmad Shah Medical Centre (SASMEC) International Islamic University Malaysia, Kuantan, MYS
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Schneider BJ, Ehsanian R, Rosati R, Huynh L, Levin J, Kennedy DJ. Validity of Physical Exam Maneuvers in the Diagnosis of Sacroiliac Joint Pathology. PAIN MEDICINE 2021; 21:255-260. [PMID: 31393577 DOI: 10.1093/pm/pnz183] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND A combination of physical examination maneuvers is currently considered necessary to help predict who will respond to injections in the sacroiliac joint. However, the literature on this topic currently consists of conflicting studies, with one showing the value of a combination of exam maneuvers and the other showing no real value. OBJECTIVE To determine the diagnostic validity of sacroiliac joint (SIJ) physical exam maneuvers using anesthetic intra-articular injection as a reference standard. DESIGN A single institution prospective study. PARTICIPANTS Patients with the clinical diagnosis of SIJ pain and referred for SIJ injection were enrolled. MAIN OUTCOME MEASURE Numeric rating scale (NRS) to assess pain intensity. RESULTS Participants underwent fluoroscopically guided SIJ intra-articular injection with 1 cc of 2% lidocaine and 1 cc of triamcinolone 40 mg. Patients' pain was assessed via 0-10 NRS pre-injection and immediately postinjection to determine positive anesthetic response to the injection. Six physical exam maneuvers (thigh thrust, Geanslen's test, FABER test, distraction test, compression test, and sacral thrust) were performed pre-injection and 15 minutes postinjection. The results of these SIJ physical exam maneuvers were evaluated singly and in combinations for diagnostic power in relation to a positive anesthetic response (>80% relief) to the injection. No association was found between a single SIJ physical exam maneuver or combination of maneuvers and anesthetic response to the injection. CONCLUSIONS In this cohort, patient physical exam maneuvers to identify intra-articular SIJ pain did not demonstrate diagnostic value when compared with the reference standard of an intra-articular anesthetic block.
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Affiliation(s)
- Byron J Schneider
- Department of Physical Medicine and Rehabilitation, Vanderbilt University, Nashville, Tennessee
| | - Reza Ehsanian
- Department of Physical Medicine and Rehabilitation, Vanderbilt University, Nashville, Tennessee.,Department of Neurosurgery, Stanford University, Palo Alto, California
| | - Renee Rosati
- Department of Physical Medicine and Rehabilitation, Vanderbilt University, Nashville, Tennessee
| | - Lisa Huynh
- Department of Neurosurgery, Stanford University, Palo Alto, California
| | - Josh Levin
- Department of Neurosurgery, Stanford University, Palo Alto, California.,Divisions of Physical Medicine & Rehabilitation and Spine, Department of Orthopaedic Surgery, Stanford University, Redwood City, California, USA
| | - David J Kennedy
- Department of Physical Medicine and Rehabilitation, Vanderbilt University, Nashville, Tennessee
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Schneider BJ, Ehsanian R, Huynh L, Levin J, Zheng P, Kennedy DJ. Pain and Functional Outcomes After Sacroiliac Joint Injection with Anesthetic and Corticosteroid at Six Months, Stratified by Anesthetic Response and Physical Exam Maneuvers. PAIN MEDICINE 2020; 21:32-40. [PMID: 31106837 DOI: 10.1093/pm/pnz111] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE To evaluate sacroiliac joint (SIJ) injection outcomes with local anesthetic and corticosteroid. DESIGN Prospective cohort. SETTING Single academic medical center. METHODS Thirty-four patients referred for SIJ injection with a clinical diagnosis of SIJ pain underwent injections with 1:1 mixture of 2% lidocaine and triamcinolone 40 mg/mL. Pain provocation physical exam (PE) maneuvers were recorded immediately before and after injection. Outcome measures at two to four weeks and six months included pain numeric rating scale (NRS) and Oswestry Disability Index (ODI). RESULTS For the analysis of outcomes by the overall group (not stratified by PE and/or anesthetic block), a 58.8% (95% confidence interval [CI] = +/-16.5%) ≥2 NRS reduction, a 32.4% (95% CI = +/-15.7%) ≥50% NRS reduction, and a 38.2% (95% CI = +/-16.3%) ≥30% ODI reduction were observed at two to four weeks, with similar improvements at six months. Outcomes stratified based on pre-injection PE did not reveal significant differences at either time point. The stratification based on the presence of 100% postinjection anesthetic response demonstrated a significant difference at two to four weeks for ≥50% NRS improvement. The true positive/true negative group (TP/TN) stratification demonstrated a significant difference for ≥50% NRS improvement at two to four weeks, whereas six-month outcomes for TP/TN demonstrated significant differences for ≥50% NRS and ≥30% ODI improvement. An increased injection response was observed with stratification of patients more likely to have true SIJ pain (i.e., TP), with TP/TN stratification demonstrating a 75% (95% CI = +/-30.0%) ≥2 NRS improvement and a 62.5% (95% CI = +/-33.5%) improvement of ≥50% NRS and ≥30% ODI for the TP group at two to four weeks, with similar results at six months. CONCLUSIONS SIJ steroid injection based on referral clinical diagnosis is unlikely to demonstrate true injection efficacy, and more specific selection criteria are warranted.
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Affiliation(s)
- Byron J Schneider
- Department of Physical Medicine and Rehabilitation, Vanderbilt University, Nashville, Tennessee
| | - Reza Ehsanian
- Department of Physical Medicine and Rehabilitation, Vanderbilt University, Nashville, Tennessee.,Divisions of Physical Medicine & Rehabilitation and Spine, Department of Orthopaedic Surgery, Stanford University, Redwood City, California
| | - Lisa Huynh
- Divisions of Physical Medicine & Rehabilitation and Spine, Department of Orthopaedic Surgery, Stanford University, Redwood City, California
| | - Josh Levin
- Divisions of Physical Medicine & Rehabilitation and Spine, Department of Orthopaedic Surgery, Stanford University, Redwood City, California.,Department of Neurosurgery, Stanford University, Palo Alto, California
| | - Patricia Zheng
- Divisions of Physical Medicine & Rehabilitation and Spine, Department of Orthopaedic Surgery, Stanford University, Redwood City, California.,Department of Orthopaedic Surgery, University of California San Francisco, San Francisco, California, USA
| | - David J Kennedy
- Department of Physical Medicine and Rehabilitation, Vanderbilt University, Nashville, Tennessee
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Zheng P, Schneider BJ, Yang A, McCormick ZL. Image‐Guided Sacroiliac Joint Injections: an Evidence‐based Review of Best Practices and Clinical Outcomes. PM R 2019; 11 Suppl 1:S98-S104. [DOI: 10.1002/pmrj.12191] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Affiliation(s)
- Patricia Zheng
- Department of Orthopaedic SurgeryUniversity of California San Francisco San Francisco CA
| | - Byron J. Schneider
- Department of Physical Medicine and RehabilitationVanderbilt University Nashville TN
| | - Aaron Yang
- Department of Physical Medicine and RehabilitationVanderbilt University Nashville TN
| | - Zachary L. McCormick
- Department of Physical Medicine and RehabilitationUniversity of Utah Salt Lake City UT
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Mao G, Aldahak N, Kusyk D, Yeager M, Cook D, Cameron J, Cheng B, Oh M. A consideration for the utility of the post-operative Oswestry Disability Index for measuring outcomes after sacroiliac joint fusion. Orthop Rev (Pavia) 2018; 10:7549. [PMID: 30057723 PMCID: PMC6042050 DOI: 10.4081/or.2018.7549] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2017] [Accepted: 02/18/2018] [Indexed: 11/23/2022] Open
Abstract
Sacroiliac joint (SIJ) dysfunction and its surgical treatment remain a controversial topic in spine surgery. Determining success after SIJ fusion may be difficult due to preexisting back pain, lumbar fusion (LF), and functional disability. We examine the utility of Oswestry Disability Index (ODI) as a measure of clinical outcomes after minimally invasive SIJ fusion. A retrospective review of 24 patients with at least 12- months follow-up. Patients were divided into two groups based on presence of previous LF. Their post-operative ODI was compared with overall satisfaction, pain reduction, and return to work status. No difference in demographics was found in patients with and without prior LF with 92% of patients reporting lower post-operative pain and 96% being satisfied. Presence of LF did not show any statistically significant differences in pain or satisfaction. However, patient with prior LF reported lower ODI than those without LF at 1-year post-operatively (P=0.015). Postoperative ODI may give a falsely pessimistic impression of outcomes in SIJ fusion patients with prior LF, and its use and limitations should be carefully considered in future studies.
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Affiliation(s)
- Gordon Mao
- Department of Neurosurgery, Allegheny General Hospital, Pittsburgh, PA, USA
| | - Nouman Aldahak
- Hopital Lariboisiere-Fernand-Widal, Hopitaux Universitaires Sant-Louis Lariboisiere Fernand-Widal, Paris, France
| | - Dorian Kusyk
- Department of Neurosurgery, Allegheny General Hospital, Pittsburgh, PA, USA
| | - Matthew Yeager
- Department of Neurosurgery, Allegheny General Hospital, Pittsburgh, PA, USA
| | - Daniel Cook
- Department of Neurosurgery, Allegheny General Hospital, Pittsburgh, PA, USA
| | - Jeffrey Cameron
- Department of Neurosurgery, Allegheny General Hospital, Pittsburgh, PA, USA
| | - Boyle Cheng
- Department of Neurosurgery, Allegheny General Hospital, Pittsburgh, PA, USA
| | - Michael Oh
- Department of Neurosurgery, Allegheny General Hospital, Pittsburgh, PA, USA.,Department of Neurosurgery, Drexel University College of Medicine, Pittsburgh, PA, USA
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Schneider BJ, Huynh L, Levin J, Rinkaekan P, Kordi R, Kennedy DJ. Does Immediate Pain Relief After an Injection into the Sacroiliac Joint with Anesthetic and Corticosteroid Predict Subsequent Pain Relief? PAIN MEDICINE 2017; 19:244-251. [DOI: 10.1093/pm/pnx104] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
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Han SH, Park KD, Cho KR, Park Y. Ultrasound versus fluoroscopy-guided medial branch block for the treatment of lower lumbar facet joint pain: A retrospective comparative study. Medicine (Baltimore) 2017; 96:e6655. [PMID: 28422871 PMCID: PMC5406087 DOI: 10.1097/md.0000000000006655] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
The aim of this study was to compare the mid-term effects and benefits of ultrasound (US)-guided and fluoroscopy (FL)-guided medial branch blocks (MBBs) for chronic lower lumbar facet joint pain through pain relief, functional improvement, and injection efficiency evaluation.Patients with chronic lumbar facet joint pain who received US (n = 68) or FL-guided MBBs (n = 78) were included in this retrospective study. All procedures were performed under FL or US guidance. Complication frequency, therapeutic effects, functional improvement, and the injection efficiency of MBBs were compared at 1, 3, and 6 months after the last injection.Both the Oswestry Disability Index (ODI) and the verbal numeric pain scale (VNS) improved at 1, 3, and 6 months after the last injections in both groups. Statistical differences were not observed in ODI and VNS between the groups (P > .05). The proportion of patients who reported successful treatment outcomes showed no significant differences between the groups at different time points. Logistic regression analysis showed that sex, pain duration, injection methods, number of injections, analgesic use, and age were not independent predictors of a successful outcome. US guidance was associated with a significantly shorter performance time.US-guided MBBs did not show significant differences in analgesic effect and functional improvement compared with the FL-guided approach. Therefore, by considering our data from this retrospective study, US-guided MBBs warrant consideration in the conservative management of lower lumbar facet joint pain.
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Affiliation(s)
- Seung Hoon Han
- Department of Rehabilitation Medicine, Hanyang University College of Medicine, Seoul, Republic of Korea
| | - Ki Deok Park
- Department of Rehabilitation Medicine, Gachon University, Gil Medical Center, Incheon
| | | | - Yongbum Park
- Department of Rehabilitation Medicine, Sanggye Paik Hospital, Inje University College of Medicine, Seoul, Republic of Korea
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Fluoroscopically Guided Sacroiliac Joint Injections: Comparison of the Effects of Intraarticular and Periarticular Injections on Immediate and Short-Term Pain Relief. AJR Am J Roentgenol 2016; 207:1055-1061. [DOI: 10.2214/ajr.15.15779] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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De Luigi AJ, Kennedy DJ. Safety Implications for Lumbar Epidural Injections: Caudal, Interlaminar, and Transforaminal Approaches. CURRENT PHYSICAL MEDICINE AND REHABILITATION REPORTS 2016. [DOI: 10.1007/s40141-016-0116-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Stegemöller EL, Roper J, Hass CJ, Kennedy DJ. Changes in gait kinematics and lower back muscle activity post-radiofrequency denervation of the zygapophysial joint: a case study. Spine J 2015; 15:e21-7. [PMID: 24120824 DOI: 10.1016/j.spinee.2013.06.061] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2011] [Revised: 05/02/2013] [Accepted: 06/18/2013] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Using diagnostic anesthetic blocks, the lumbar zygapophysial (facet) joint has been shown to be the primary cause of pain in approximately 15% of patients with chronic low back pain. Radiofrequency neurotomy (RFN) of the lumbar medial branch innervating the zygapophysial joint has been shown to provide a significant decrease in pain in patients selected by dual comparative anesthetic blocks, but quantitative improvements in mobility have not been fully elucidated. A theoretical concern with RFN is that the multifidus muscle, a stabilizing paraspinal muscle, is also denervated during this procedure, which may have adverse effects on mobility and spine stability. PURPOSE The purpose of this study was to examine gait kinematics and muscle activity of the low back during treadmill walking both before and after RFN. STUDY DESIGN Case study. PATIENT SAMPLE One 33-year-old female, with 15 years of chronic left low back pain and a diagnosis of L4/L5 lumbar zygapophysial joint pain by dual comparative anesthetic blocks was studied. OUTCOME MEASURES Self-reported measures of perceived pain and effort; in addition to physiologic measures of heart rate, gait kinematics and surface electromyography (EMG) activity of the multifidus and erector spinae muscles were collected before and after the procedure. METHODS The participant walked for 15 consecutive minutes on a treadmill. The first and last 5-minute intervals were at a self-selected pace, and the middle 5-minute interval was at a 50% increase of the self-selected pace. Gait kinematics and lumbar paraspinal surface EMG activity were recorded during the last minute of each walking interval. Heart rate, perceived effort, and perceived pain were also collected at the end of each walking interval. Data were collected both 7 and 1 days before RFN, and on the following days post-RFN: 0, 8, 14, 28, and 58. RESULTS Perceived effort did not change despite an increase in treadmill speed and heart rate. Pain decreased by 60% in the first two weeks and by 92% by 4 weeks post-RFN. There were also gradual positive changes in gait kinematics across all post-sessions and an immediate and sustained decrease in surface EMG activity over the left multifidus and erector spinae muscles following RFN. CONCLUSIONS The results of this pilot study are the first to show quantitative positive changes in gait and muscle activity post-RFN, suggesting that the relationship between this procedure and mobility warrant further investigation.
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Affiliation(s)
- Elizabeth L Stegemöller
- Department of Applied Physiology and Kinesiology, University of Florida, P.O. Box 118205, Gainesville, FL 32611-8205, USA
| | - Jaimie Roper
- Department of Applied Physiology and Kinesiology, University of Florida, P.O. Box 118205, Gainesville, FL 32611-8205, USA
| | - Chris J Hass
- Department of Applied Physiology and Kinesiology, University of Florida, P.O. Box 118205, Gainesville, FL 32611-8205, USA
| | - David J Kennedy
- Department of Orthopaedics, Divisions of Spine and Rehabilitation Medicine, Stanford University, 450 Broadway St Pavilion C, MC 6342, Redwood City, CA 94063, USA.
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Epidural steroid injections for radicular lumbosacral pain: a systematic review. Phys Med Rehabil Clin N Am 2014; 25:471-89.e1-50. [PMID: 24787344 DOI: 10.1016/j.pmr.2014.02.001] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Most clinical guidelines do not recommend routine use of epidural steroid injections for the management of chronic low back pain. However, many clinicians do not adhere to these guidelines. This comprehensive evidence overview concluded that off-label epidural steroid injections provide small short-term but not long- term leg-pain relief and improvement in function; injection of steroids is no more effective than injection of local anesthetics alone; post-procedural complications are uncommon, but the risk of contamination and serious infections is very high. The evidence does not support routine use of off-label epidural steroid injections in adults with benign radicular lumbosacral pain.
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Affiliation(s)
- E Bizzi
- Operative Unit of Rheumatology, S.Pietro Fatebenefratelli Hospital , Rome , Italy
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Adiguzel E, Kesikburun S, Yasar E, Taskaynatan MA. Major Perirectal Hematoma Complicating Sacroiliac Joint Injection. ACTA ACUST UNITED AC 2014. [DOI: 10.3109/10582452.2014.883032] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Ultrasound Guided Spine Injections: Advancement Over Fluoroscopic Guidance? CURRENT PHYSICAL MEDICINE AND REHABILITATION REPORTS 2013. [DOI: 10.1007/s40141-013-0016-z] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Patil AA, Otto D, Raikar S. Peripheral nerve field stimulation for sacroiliac joint pain. Neuromodulation 2013; 17:98-101. [PMID: 23441931 DOI: 10.1111/ner.12030] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2012] [Revised: 11/28/2012] [Accepted: 01/03/2013] [Indexed: 11/27/2022]
Affiliation(s)
- Arun Angelo Patil
- Division of Neurosurgery, University of Nebraska Medical Center, Omaha, NE, USA
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Abstract
Osteoarthritis of the spine develops as a consequence of the natural aging process and is associated with significant morbidity and health care expenditures. Effective diagnosis and treatment of the resultant pathologic conditions can be clinically challenging. Recent evidence has emerged to aid the investigating clinician in formulating an accurate diagnosis and in implementing a successful treatment algorithm. This article details the degenerative cascade that results in the osteoarthritic spine, reviews prevalence data for common painful spinal disorders, and discusses evidence-based treatment options for management of zygapophysial and sacroiliac joint arthrosis.
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Abstract
Athletes represent a specific subgroup of highly motivated patients with a unique set of social and psychological incentives. Demands placed on the lumbosacral system are high, and athletes may be particularly prone to the pathology discussed above. For this reason, it is crucial to consider the athlete as a functional whole operating in concert with intrinsic and extrinsic factors and to consider the lumbosacral system within the context of the complete kinetic chain. Spinal interventions should never be considered in isolation but rather as part of a comprehensive rehabilitation program targeting psychosocial as well as biomechanical opportunities. When interventional procedures are warranted, they should be performed according to existing guidelines regarding indication, patient selection, and technique where possible and with systems in place to maximize patient safety and to consistently monitor for response. Each of the interventions discussed above should be performed with fluoroscopic guidance, given the lack of accuracy without fluoroscopy, and generally be reserved for athletes not responding to conservative care. When returning an athlete to play after ESI, we recommend careful serial evaluation as well as involvement of appropriate family members, athletic trainers, and coaches in the decision-making process. Athletes should not return to play with any significant objective neurologic deficits. In appropriate athletes, return to play should occur with graduated and comprehensive rehabilitation as discussed above. Because evidence concerning the interventions discussed in this article is often lacking, clinical judgment is paramount regarding their allocation. The interventions explored above likely do provide viable treatment adjuncts in the carefully selected athlete but are not without risk. Athlete safety and global well being should guide any decision to pursue interventional treatment options.
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Affiliation(s)
- Daniel V Colonno
- Department of Rehabilitation Medicine, University of Washington, Seattle, WA 98195, USA.
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