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Gupt SK, Yadav G, Gupta AK. Effectiveness of Ultrasonography- and Fluoroscopy-Guided Caudal Epidural Injections in the Management of Chronic Lumbar Disc Disease: A Retrospective Comparative Study. Cureus 2024; 16:e64844. [PMID: 39156341 PMCID: PMC11330279 DOI: 10.7759/cureus.64844] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/18/2024] [Indexed: 08/20/2024] Open
Abstract
INTRODUCTION Lumbar disc disease is one of the common causes of lower back pain caused by a change in the structure of the normal disc. Most of the time, disc disease happens as a result of aging and the normal breakdown that occurs within the disc. Caudal epidural steroid injections are the popular treatment for patients with chronic low back pain that does not respond to conservative management. METHOD A retrospective survey was administered to 160 patients who had received caudal epidural injections for chronic low back pain in the past, but only 74 patients who completed the scheduled follow-ups were included in the study. They were divided into two groups based on the imaging modality used for guiding the caudal epidural steroid injections, either ultrasonography or fluoroscopy, and then assessed for improvement in pain on the Numeric Rating Scale (NRS), for functional improvement on the Oswestry Disability Index (ODI), and for satisfaction on the North American Spine Society Patient Satisfaction Scale (SSPSS). RESULTS Mean NRS pain scores improved significantly from baseline at 6.78 and 7.00 in the fluoroscopy and ultrasound groups, respectively, to 2.03 and 2.16 at 12 weeks post-procedure. The difference between the groups was not statistically significant (p > 0.05). The Oswestry Disability Index was completed at baseline and after 12 weeks of follow-up for both groups, and there was no significant difference between the two groups; the fluoroscopy group's mean Oswestry Disability Index scores were 52.4 at baseline and 35.6 at 12 weeks, whereas the scores for the ultrasound group were 50.3 at baseline and 37.9 at 12 weeks. Conversely, patient satisfaction as assessed using the SSPSS rose in both groups up to 12 weeks (p > 0.05). CONCLUSION The ultrasound- and fluoroscopy-guided caudal epidural steroid injections proved equally effective in easing the pain, disability, and satisfaction levels of patients with chronic lower back pain.
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Affiliation(s)
- Sandeep K Gupt
- Physical Medicine and Rehabilitation, King George's Medical University, Lucknow, IND
| | - Ganesh Yadav
- Physical Medicine and Rehabilitation, King George's Medical University, Lucknow, IND
| | - Anil K Gupta
- Physical Medicine and Rehabilitation, King George's Medical University, Lucknow, IND
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He X, Xiao Y, Zhang X, Zhang X, Zhang X, Wei Y, Zhang Z, Xue X, Zhang S. Low-dose CT fluoroscopy-guided interventional minimally invasive robot. Heliyon 2024; 10:e28914. [PMID: 38601523 PMCID: PMC11004810 DOI: 10.1016/j.heliyon.2024.e28914] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Revised: 02/27/2024] [Accepted: 03/26/2024] [Indexed: 04/12/2024] Open
Abstract
Background This study aimed to assess the feasibility, safety, and accuracy of a low-dose CT fluoroscopy-guided remote-controlled robotic real-time puncture procedure. Methods The study involved two control groups with Taguchi method: Group A, which underwent low-dose traditional CT-guided manual puncture (blank control), and Group B, which underwent conditional control puncture. Additionally, an experimental group, Group C, underwent CT fluoroscopy-guided remote-controlled robotic real-time puncture. In a phantom experiment, various simulated targets were punctured, while in an animal experiment, attempts were made to puncture targets in different organs of four pigs. The number of needle adjustments, puncture time, total puncture operation time, and radiation dose were analyzed to evaluate the robot system. Results Successful punctures were achieved for each target, and no complications were observed. Dates were calculated for all parameters using Taguchi method. Conclusion The low-dose CT fluoroscopy-guided puncture robot system is a safe, feasible, and equally accurate alternative to traditional manual puncture procedures.
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Affiliation(s)
- Xiaofeng He
- The First Medical Center of Chinese PLA General Hospital, Department of Diagnostic Radiology, Beijing, China
| | - Yueyong Xiao
- The First Medical Center of Chinese PLA General Hospital, Department of Diagnostic Radiology, Beijing, China
| | - Xiao Zhang
- The First Medical Center of Chinese PLA General Hospital, Department of Diagnostic Radiology, Beijing, China
| | - Xiaobo Zhang
- The First Medical Center of Chinese PLA General Hospital, Department of Diagnostic Radiology, Beijing, China
| | - Xin Zhang
- The First Medical Center of Chinese PLA General Hospital, Department of Diagnostic Radiology, Beijing, China
| | - Yingtian Wei
- The First Medical Center of Chinese PLA General Hospital, Department of Diagnostic Radiology, Beijing, China
| | - Zhongliang Zhang
- The First Medical Center of Chinese PLA General Hospital, Department of Diagnostic Radiology, Beijing, China
| | - Xiaodong Xue
- The First Medical Center of Chinese PLA General Hospital, Department of Diagnostic Radiology, Beijing, China
| | - Shiwen Zhang
- The First Medical Center of Chinese PLA General Hospital, Department of Diagnostic Radiology, Beijing, China
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Acosta Julbe JI, Mandell JC, Ermann J, Isaac Z, Gottreich JR, Zampini JM, DeFilipp M, Andrew MN, Katz JN. Predictors of Outcomes After Lumbar Intra-Articular Facet Joint Injections and Medial Branch Blocks: A Scoping Review. Spine (Phila Pa 1976) 2023; 48:1455-1463. [PMID: 37470372 PMCID: PMC10528906 DOI: 10.1097/brs.0000000000004776] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Accepted: 06/26/2023] [Indexed: 07/21/2023]
Abstract
STUDY DESIGN A scoping review. OBJECTIVE We aimed to identify and describe the factors associated with the patient-reported response after lumbar intra-articular facet joint (FJ) injections or medial branch blocks (MBBs). SUMMARY OF BACKGROUND DATA FJ osteoarthritis is among the most common causes of chronic low back pain. Management often includes FJ intra-articular injection and MBBs (which may be followed by radiofrequency ablation of the nerves innervating these joints). However, the success of these approaches is variable, prompting interest in identifying patient characteristics (imaging features, clinical signs, and among others) associated with response to these types of facet injections. MATERIALS AND METHODS We performed a literature search on factors associated with patient-reported outcomes after lumbar FJ intra-articular injections or MBBs for patients with low back pain published in English or Spanish between 2000 and 2023. We excluded duplicate papers that did not describe factors associated with outcomes or those describing other interventions. We collected data on the association of these factors with patient-reported outcomes. RESULTS Thirty-seven studies met the inclusion criteria and were analyzed. These studies evaluated factors, such as age, depression, and single photon emission computed tomography (SPECT), and among variables. Age and imaging findings of facet arthropathy were the most frequently described factors. Imaging findings of FJ arthropathy and positive SPECT were often associated with positive results after intra-articular FJ injections or MBBs. In contrast, younger age and smoking were frequently associated with less favorable clinical outcomes. CONCLUSION Numerous factors were considered in the 37 studies included in this review. Imaging findings of facet arthropathy, duration of pain, and positive SPECT were consistently associated with favorable results after facet interventions.
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Affiliation(s)
- José I. Acosta Julbe
- Orthopedic and Arthritis Center for Outcomes Research, Brigham and Women’s Hospital, Boston, Massachusetts, USA
- Department of Orthopedic Surgery, Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | - Jacob C. Mandell
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Radiology, Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | - Joerg Ermann
- Harvard Medical School, Boston, Massachusetts, USA
- Division of Rheumatology, Inflammation, and Immunity, Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | - Zacharia Isaac
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Physical Medicine and Rehabilitation, Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | - Julia R. Gottreich
- Orthopedic and Arthritis Center for Outcomes Research, Brigham and Women’s Hospital, Boston, Massachusetts, USA
- Department of Orthopedic Surgery, Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | - Jay M. Zampini
- Department of Orthopedic Surgery, Brigham and Women’s Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Miriam DeFilipp
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Radiology, Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | - Michael N. Andrew
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Physical Medicine and Rehabilitation, Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | - Jeffrey N. Katz
- Orthopedic and Arthritis Center for Outcomes Research, Brigham and Women’s Hospital, Boston, Massachusetts, USA
- Department of Orthopedic Surgery, Brigham and Women’s Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
- Division of Rheumatology, Inflammation, and Immunity, Brigham and Women’s Hospital, Boston, Massachusetts, USA
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Bogdanovic S, Sutter R, Zubler V. Spine injections: the rationale for CT guidance. Skeletal Radiol 2023; 52:1853-1862. [PMID: 36149474 PMCID: PMC10449983 DOI: 10.1007/s00256-022-04188-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Revised: 09/14/2022] [Accepted: 09/16/2022] [Indexed: 02/02/2023]
Abstract
Back pain is one of the most common medical problems and is associated with high socioeconomic costs. Imaging-guided spinal injections are a minimally invasive method to evaluate where the back pain is originating from, and to treat patients with radicular pain or spinal stenosis with infiltration of corticosteroids. CT-guided spine injections are a safe procedure, characterized by precise needle placement, excellent visualization of the relevant anatomical structures, and low radiation exposure for the patient and the interventional radiologist. In this review article, the variety of applications of CT-guided injections (focused on nerve roots and epidural injections) and the optimal injection procedure as well as risks and side effects are discussed.
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Affiliation(s)
- Sanja Bogdanovic
- Department of Radiology, Orthopedic University Hospital Balgrist, Zurich, Forchstrasse 340, 8008 Zurich, Switzerland
| | - Reto Sutter
- Department of Radiology, Orthopedic University Hospital Balgrist, Zurich, Forchstrasse 340, 8008 Zurich, Switzerland
| | - Veronika Zubler
- Department of Radiology, Orthopedic University Hospital Balgrist, Zurich, Forchstrasse 340, 8008 Zurich, Switzerland
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Stratchko L, Pitts J, Symanski J, Ross A, Davis K, Monroe E, Rosas H. Rationale for fluoroscopic guidance in spine injections. Skeletal Radiol 2023; 52:1841-1851. [PMID: 36102947 DOI: 10.1007/s00256-022-04181-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Revised: 09/01/2022] [Accepted: 09/01/2022] [Indexed: 02/02/2023]
Abstract
Spine injections are commonly performed in the treatment of back pain. The purpose of this article is to review the current literature surrounding image guided spine injections focusing on scenarios where fluoroscopic guidance can be advantageous in addition to discussing similarities among the different modalities.
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Affiliation(s)
- Lindsay Stratchko
- School of Medicine and Public Health Department of Radiology, University of Wisconsin, 600 Highland Ave., Madison, WI, 53792, USA.
| | - Jennifer Pitts
- School of Medicine and Public Health Department of Radiology, University of Wisconsin, 600 Highland Ave., Madison, WI, 53792, USA
| | - John Symanski
- School of Medicine and Public Health Department of Radiology, University of Wisconsin, 600 Highland Ave., Madison, WI, 53792, USA
| | - Andrew Ross
- School of Medicine and Public Health Department of Radiology, University of Wisconsin, 600 Highland Ave., Madison, WI, 53792, USA
| | - Kirkland Davis
- School of Medicine and Public Health Department of Radiology, University of Wisconsin, 600 Highland Ave., Madison, WI, 53792, USA
| | - Eric Monroe
- School of Medicine and Public Health Department of Radiology, University of Wisconsin, 600 Highland Ave., Madison, WI, 53792, USA
| | - Humberto Rosas
- School of Medicine and Public Health Department of Radiology, University of Wisconsin, 600 Highland Ave., Madison, WI, 53792, USA
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Abstract
An expanding array of image-guided spine interventions have the potential to provide immediate and effective pain relief. Innovations in spine intervention have proceeded rapidly, with clinical adoption of new techniques at times occurring before the development of bodies of evidence to establish efficacy. Although new spine interventions have been evaluated by clinical trials, acceptance of results has been hindered by controversies regarding trial methodology. This article explores controversial aspects of four categories of image-guided interventions for painful conditions: spine interventions for postdural puncture headache resulting from prior lumbar procedures, epidural steroid injections for cervical and lumbar radiculopathy, interventions for facet and sacroiliac joint pain, and vertebral augmentations for compression fractures. For each intervention, we summarize the available literature, with an emphasis on persistent controversies, and discuss how current areas of disagreement and challenge may shape future research and innovation. Despite the ongoing areas of debate regarding various aspects of these procedures, effective treatments continue to emerge and show promise for aiding relief of a range of debilitating conditions.
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Radiation dose of fluoroscopy-guided versus ultralow-dose CT-fluoroscopy-guided lumbar spine epidural steroid injections. Skeletal Radiol 2022; 51:1055-1062. [PMID: 34611727 DOI: 10.1007/s00256-021-03920-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Revised: 09/21/2021] [Accepted: 09/21/2021] [Indexed: 02/02/2023]
Abstract
OBJECTIVE Compare radiation dose of lumbar spine epidural steroid injections (ESIs) performed under fluoroscopy guidance and ultralow-dose CT-fluoroscopy guidance. MATERIALS AND METHODS Retrospective review of consecutive lumbar ESIs performed using fluoroscopy, between May 2017 and April 2019, and using ultralow-dose CT-fluoroscopy, between August 2019 and February 2021, was performed. Ultralow-dose CT-fluoroscopy technique omits a planning CT scan, utilizes CT-fluoroscopy, and minimizes radiation dose parameters. Patient characteristics (age, sex, height, weight, body mass index (BMI)), procedural characteristics (anatomic level, type of ESI, procedure time, pain reduction, complications, trainee participation), and radiation dose were compared. Chi-square tests and two-sample t-tests were performed for statistical analysis. RESULTS One hundred and forty-seven patients (mean age 55.8 ± 16.7; 85 women) underwent ESIs using fluoroscopy. Sixty-six patients (mean age 60.9 ± 16.7; 33 women) underwent ESIs using ultralow-dose CT-fluoroscopy. The effective dose for the fluoroscopy group was 0.30 mSv ± 0.34, compared to 0.15 mSV ± 0.11 for ultralow-dose CT-fluoroscopy (p < 0.001). The average age in the CT-fluoroscopy group was older (p = 0.04), and there was more trainee participation in the fluoroscopy group (p < 0.001); otherwise there was no statistically significant difference in patient or procedural characteristics between the conventional fluoroscopy group and the ultralow-dose CT-fluoroscopy group. There was no statistically significant difference in immediate post-procedure pain reduction between the groups (p = 0.16). Four intrathecal injections occurred only in the fluoroscopy group, though this difference was not significant (p = 0.18). CONCLUSION Ultralow-dose CT-fluoroscopy technique for image-guided lumbar spine ESIs can lower radiation dose compared to fluoroscopy-guided technique.
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Kamp JPM, Bartlett J, Fahmy A, To K, Hossain R, Akula M. CT-guided vs. fluoroscopically guided transforaminal epidural steroid injections for lumbar radiculopathy: a comparison of efficacy, safety and cost. Arch Orthop Trauma Surg 2022; 143:2355-2361. [PMID: 35420357 PMCID: PMC10110633 DOI: 10.1007/s00402-022-04436-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Accepted: 03/25/2022] [Indexed: 02/07/2023]
Abstract
INTRODUCTION There are no formal guidelines for whether CT-guided or fluoroscopy-guided TFESI should be undertaken for patients with symptoms of lumbar nerve root irritation and corresponding nerve impingement. Here, we sought to compare the efficacy, safety and cost of computer tomography (CT)-guided and fluoroscopically guided transforaminal epidural steroid injection (TFESI). MATERIALS AND METHODS All patients who underwent lumbar TFESI at our institution between June 2016 and June 2018 were identified. Six-week follow-up outcomes were categorised. The radiation doses and associated cost was retrieved from our institution's costing system. RESULTS One hundred and sixteen patients were included (CT-50; fluoroscopy-56). There were no complications. More patients were discharged 6 weeks after CT-guided lumbar TFESI when compared with fluoroscopically guided TFESI (CT-23, fluoroscopy-14 (P = 0.027)). There was no difference in the number of patients who were referred to surgery (P = 0.18), for further pain management (P = 0.45), or for further TFESI (P = 0.43). The effective radiation dose was significantly higher for CT-guided TFESI (CT-5.73 mSv (3.87 to 7.76); fluoroscopy-0.55 mSv (0.11 to 1.4) (P < 0.01)). The total cost for CT-guided lumbar TFESI was £237.50 (£235 to £337), over £800 less than under fluoroscopic guidance (£1052 (£892.80 to £1298.00), P < 0.01)). Removing cost associated with staff and theatre use (staffing, theatre, medical indemnity and overheads) revealed CT-guided lumbar TFESI to be less expensive than if the procedure was fluoroscopy-guided-CT-guided: £132.6 (130.8 to 197.5); fluoroscopy: £237.4 (£209.2 to £271.9) (P = 0.019). CONCLUSIONS CT-guided TFESI was associated with a higher discharge rate, a lower cost, but a ten times higher radiation dose when compared with fluoroscopically guided TFESI. Prospective studies are required to compare the efficacy of these procedures and to investigate how the radiation dose of CT-guided TFESI can be reduced without jeopardising efficacy or safety.
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Affiliation(s)
- Jozef P M Kamp
- Department of Trauma and Orthopaedics, Basildon and Thurrock University Hospital, Basildon, UK
| | - Jonathan Bartlett
- Department of Trauma and Orthopaedics, Rotorua Hospital, Rotorua, New Zealand
| | - Amr Fahmy
- Department of Trauma and Orthopaedics, Basildon and Thurrock University Hospital, Basildon, UK
| | - Kendrick To
- Division of Trauma and Orthopaedics, Department of Surgery, University of Cambridge, Addenbrooke's Hospital, Cambridge, UK.
| | - Rumana Hossain
- Department of Trauma and Orthopaedics, Basildon and Thurrock University Hospital, Basildon, UK
| | - Maheswara Akula
- Department of Trauma and Orthopaedics, Basildon and Thurrock University Hospital, Basildon, UK
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Reuschel V, Scherlach C, Pfeifle C, Krause M, Struck MF, Hoffmann KT, Schob S. Treatment Effect of CT-Guided Periradicular Injections in Context of Different Contrast Agent Distribution Patterns. Diagnostics (Basel) 2022; 12:diagnostics12040787. [PMID: 35453835 PMCID: PMC9028051 DOI: 10.3390/diagnostics12040787] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2022] [Revised: 03/08/2022] [Accepted: 03/18/2022] [Indexed: 02/01/2023] Open
Abstract
Acutely manifesting radicular pain syndromes associated with degenerations of the lower spine are frequent ailments with a high rate of recurrence. Part of the conservative management are periradicular infiltrations of analgesics and steroids. The purpose of this study is to evaluate the dependence of the clinical efficacy of CT-guided periradicular injections on the pattern of contrast distribution and to identify the best distribution pattern that is associated with the most effective pain relief. Using a prospective study design, 161 patients were included in this study, ensuring ethical standards. Statistical analysis was performed, with the level of statistical significance set at p = 0.05. A total of 37.9% of patients experienced significant but not long-lasting (four weeks on average) complete pain relief. A total of 44.1% of patients experienced prolonged, subjectively satisfying pain relief of more than four weeks to three months. A total of 18% of patients had complete and sustained relief for more than six months. A significant correlation exists between circumferential, large area contrast distribution including the zone of action between the disc and affected nerve root contrast distribution pattern with excellent pain relief. Our results support the value of CT-guided contrast injection for achieving a good efficacy, and, if necessary, indicative repositioning of the needle to ensure a circumferential distribution pattern of corticosteroids for the sufficient treatment of radicular pain in degenerative spine disease.
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Affiliation(s)
- Vera Reuschel
- Institut für Neuroradiologie, Universitätsklinikum Leipzig AöR, Liebigstr. 20, 04103 Leipzig, Germany; (V.R.); (C.S.); (K.-T.H.)
- Institut für Diagnostische und Interventionelle Neuroradiologie, Universitätsmedizin Göttingen, Robert-Koch-Str. 40, 37075 Göttingen, Germany
| | - Cordula Scherlach
- Institut für Neuroradiologie, Universitätsklinikum Leipzig AöR, Liebigstr. 20, 04103 Leipzig, Germany; (V.R.); (C.S.); (K.-T.H.)
| | - Christian Pfeifle
- Klinik und Poliklinik für Orthopädie, Unfallchirurgie und Plastische Chirurgie, Universitätsklinikum Leipzig AöR, Liebigstr. 20, 04103 Leipzig, Germany;
| | - Matthias Krause
- Klinik und Poliklinik für Neurochirurgie, Universitätsklinikum Leipzig AöR, Liebigstr. 20, 04103 Leipzig, Germany;
| | - Manuel Florian Struck
- Klinik und Poliklinik für Anästhesiologie und Intensivtherapie, Universitätsklinikum Leipzig AöR, Liebigstr. 20, 04103 Leipzig, Germany;
| | - Karl-Titus Hoffmann
- Institut für Neuroradiologie, Universitätsklinikum Leipzig AöR, Liebigstr. 20, 04103 Leipzig, Germany; (V.R.); (C.S.); (K.-T.H.)
| | - Stefan Schob
- Abteilung für Neuroradiologie, Universitätsklinik und Poliklinik für Radiologie, Universitätsklinikum Halle (Saale) Ernst-Grube-Str. 40, 06120 Halle (Saale), Germany
- Correspondence: ; Tel.: +49-34-5557-2432
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CT-guided transforaminal epidural steroid injection for discogenic lumbar radiculopathy: influence of contrast dispersion and radiologist's experience on clinical outcome. Skeletal Radiol 2022; 51:783-793. [PMID: 34382098 PMCID: PMC8854304 DOI: 10.1007/s00256-021-03881-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2021] [Revised: 07/15/2021] [Accepted: 07/25/2021] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To investigate the impact of contrast dispersion pattern/location during lumbar CT-guided transforaminal epidural steroid injection (TFESI) and experience of the performing radiologist on therapeutic outcome. MATERIALS AND METHODS In this single-center retrospective cohort study, two observers analyzed contrast dispersion during CT-guided TFESI of 204 patients (age 61.1 ± 14 years) with discogenic unilateral single-level L4 or L5 radiculopathy. The contrast dispersion pattern was classified as "focal," "linear," or "tram-track"; the location was divided into "extraforaminal," "foraminal," or "recessal." Pain was assessed before and 4 weeks after treatment using a numerical rating scale (0, no pain; 10, intolerable pain). Additionally, the patient global impression of change (PGIC) was assessed. The TFESI was performed by musculoskeletal radiologists (experience range: first year of musculoskeletal fellowship training to 19 years). Contrast pattern/location and radiologist's experience were compared between "good responder" (≥ 50% pain reduction) and "poor responder" (< 50%). A p-value < 0.05 was considered to be statistically significant. RESULTS Overall, CT-guided TFESI resulted in a substantial pain reduction in 46.6% of patients with discogenic radiculopathy. The contrast dispersion pattern and location had no effect on pain relief (p = 0.75 and p = 0.09) and PGIC (p = 0.70 and p = 0.21) 4 weeks after TFESI. Additionally, the experience of the radiologist had no influence on pain reduction (p = 0.92) or PGIC (p = 0.75). Regarding pre-interventional imaging findings, both the location and grading of nerve compression had no effect on pain relief (p = 0.91 and p = 0.85) and PGIC (p = 0.18 and p = 0.31). CONCLUSION Our results indicate that neither contrast agent dispersion/location nor the experience of the radiologist allows predicting the therapeutic outcome 4 weeks after the procedure.
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Predictive value of immediate pain relief after lumbar transforaminal epidural injection with local anesthetics and steroids for single level radiculopathy. Skeletal Radiol 2022; 51:1975-1985. [PMID: 35394165 PMCID: PMC9381491 DOI: 10.1007/s00256-022-04051-3] [Citation(s) in RCA: 1] [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: 03/01/2022] [Revised: 03/31/2022] [Accepted: 03/31/2022] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To assess the predictive value of immediate pain-relief after CT-guided transforaminal epidural steroid injection (TFESI) including local anesthetics for longer-term pain relief and patients' global impression of change (PGIC) after 4 weeks. MATERIALS AND METHODS One hundred ninety-three patients (age 55.4 ± 14.9) with single-level discogenic lumbar radiculopathy and subsequent TFESI were included. Pain scores were recorded before (NRS0), 15 min (NRS15min), and 4 weeks (NRS4w) after treatment using a numerical-rating-scale (NRS; 0, no pain; 10, intolerable pain). Additionally, the PGIC was assessed after 4 weeks. Two fellowship-trained musculoskeletal radiologists evaluated nerve compression of the injected level and contrast dispersion. Spearman's rank and point-biserial correlation were applied to assess associations between outcome variables and demographics/imaging findings. A p-value < 0.05 was considered to be statistically significant. RESULTS There was a significant positive correlation between immediate pain-relief and longer-term pain-reduction (r = 0.24, p = 0.001) with an odds ratio of 2.0 (CI: 1.1-3.6). A good short-term response (NRS15min ≥ 50% reduction) was associated with a persistent longer-term good response (NRS4w ≥ 50% reduction) in 59.7% (CI: 50.9-68.0%) of patients. There was no association between short-term pain-relief and PGIC after 4 weeks (p = 0.18). Extent and location of nerve compression and contrast dispersion during TFESI did not correlate with longer-term pain-relief (all p ≥ 0.07). CONCLUSION Our results indicate a significant positive correlation between immediate post-procedural and longer-term pain relief after TFESI in patients with lumbar radiculopathy; however, no effect of short-term pain relief is seen on PGIC after 4 weeks. Patients with good longer-term outcome (≥ 50% pain reduction) are twice as likely to have already shown good immediate pain reduction after TFESI.
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Carassiti M, Pascarella G, Strumia A, Russo F, Papalia GF, Cataldo R, Gargano F, Costa F, Pierri M, De Tommasi F, Massaroni C, Schena E, Agrò FE. Epidural Steroid Injections for Low Back Pain: A Narrative Review. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 19:ijerph19010231. [PMID: 35010492 PMCID: PMC8744824 DOI: 10.3390/ijerph19010231] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Revised: 12/19/2021] [Accepted: 12/22/2021] [Indexed: 05/03/2023]
Abstract
Low back pain represents a significant socioeconomic burden. Several nonsurgical medical treatments have been proposed for the treatment of this disabling condition. Epidural steroid injections (ESIs) are commonly used to treat lumbosacral radicular pain and to avoid surgery. Even though it is still not clear which type of conservative intervention is superior, several studies have proved that ESIs are able to increase patients' quality of life, relieve lumbosacral radicular pain and finally, reduce or delay more invasive interventions, such as spinal surgery. The aim of this narrative review is to analyze the mechanism of action of ESIs in patients affected by low back pain and investigate their current application in treating this widespread pathology.
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Affiliation(s)
- Massimiliano Carassiti
- Unit of Anaesthesia, Intensive Care and Pain Management, Department of Medicine, Campus Bio-Medico University of Rome, 00128 Rome, Italy; (G.P.); (A.S.); (R.C.); (F.G.); (F.C.); (F.E.A.)
- Correspondence:
| | - Giuseppe Pascarella
- Unit of Anaesthesia, Intensive Care and Pain Management, Department of Medicine, Campus Bio-Medico University of Rome, 00128 Rome, Italy; (G.P.); (A.S.); (R.C.); (F.G.); (F.C.); (F.E.A.)
| | - Alessandro Strumia
- Unit of Anaesthesia, Intensive Care and Pain Management, Department of Medicine, Campus Bio-Medico University of Rome, 00128 Rome, Italy; (G.P.); (A.S.); (R.C.); (F.G.); (F.C.); (F.E.A.)
| | - Fabrizio Russo
- Department of Orthopaedic and Trauma Surgery, Campus Bio-Medico University of Rome, 00128 Rome, Italy; (F.R.); (G.F.P.)
| | - Giuseppe Francesco Papalia
- Department of Orthopaedic and Trauma Surgery, Campus Bio-Medico University of Rome, 00128 Rome, Italy; (F.R.); (G.F.P.)
| | - Rita Cataldo
- Unit of Anaesthesia, Intensive Care and Pain Management, Department of Medicine, Campus Bio-Medico University of Rome, 00128 Rome, Italy; (G.P.); (A.S.); (R.C.); (F.G.); (F.C.); (F.E.A.)
| | - Francesca Gargano
- Unit of Anaesthesia, Intensive Care and Pain Management, Department of Medicine, Campus Bio-Medico University of Rome, 00128 Rome, Italy; (G.P.); (A.S.); (R.C.); (F.G.); (F.C.); (F.E.A.)
| | - Fabio Costa
- Unit of Anaesthesia, Intensive Care and Pain Management, Department of Medicine, Campus Bio-Medico University of Rome, 00128 Rome, Italy; (G.P.); (A.S.); (R.C.); (F.G.); (F.C.); (F.E.A.)
| | - Michelangelo Pierri
- Integrated Sleep Surgery Team UCBM, Unit of Otolaryngology, Integrated Therapies in Otolaryngology, Campus Bio-Medico University of Rome, 00128 Rome, Italy;
| | - Francesca De Tommasi
- Unit of Measurements and Biomedical Instrumentation, Department of Engineering, Campus Bio-Medico University of Rome, 00128 Rome, Italy; (F.D.T.); (C.M.); (E.S.)
| | - Carlo Massaroni
- Unit of Measurements and Biomedical Instrumentation, Department of Engineering, Campus Bio-Medico University of Rome, 00128 Rome, Italy; (F.D.T.); (C.M.); (E.S.)
| | - Emiliano Schena
- Unit of Measurements and Biomedical Instrumentation, Department of Engineering, Campus Bio-Medico University of Rome, 00128 Rome, Italy; (F.D.T.); (C.M.); (E.S.)
| | - Felice Eugenio Agrò
- Unit of Anaesthesia, Intensive Care and Pain Management, Department of Medicine, Campus Bio-Medico University of Rome, 00128 Rome, Italy; (G.P.); (A.S.); (R.C.); (F.G.); (F.C.); (F.E.A.)
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Gimarc DC, Stratchko LM, Ho CK. Spinal Injections. Semin Musculoskelet Radiol 2021; 25:756-768. [PMID: 34937116 DOI: 10.1055/s-0041-1735912] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Spinal pain is a common complaint and cause of disability in the United States, affecting most individuals at some point in their lives. The complex anatomy of the spine leads to multiple potential and coexisting etiologies for pain, and the differentiation of these sources can present a diagnostic challenge. Image-guided spinal injections can provide both diagnostic information identifying pain location as well as prolonged therapeutic relief as an alternative to medical management. Anesthetic and corticosteroid medications can be administered within the epidural space through transforaminal or interlaminar approaches, blocking various sensory nerves, or directly within the facet joints. Proceduralists must be aware of associated patient considerations, techniques, and potential complications to perform the procedures safely. We discuss image-guided spinal injection techniques, based on best practices and our experiences.
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Affiliation(s)
- David C Gimarc
- Department of Radiology, University of Colorado, Anschutz Medical Campus, Aurora, Colorado
| | - Lindsay M Stratchko
- Department of Radiology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Corey K Ho
- Department of Radiology, University of Colorado, Anschutz Medical Campus, Aurora, Colorado
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Dillon WP. 50th anniversary of computed tomography: past and future applications in clinical neuroscience. J Med Imaging (Bellingham) 2021; 8:052112. [PMID: 34676278 PMCID: PMC8523063 DOI: 10.1117/1.jmi.8.5.052112] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Accepted: 09/27/2021] [Indexed: 12/20/2022] Open
Abstract
Purpose: It has been 50 years since computed tomography was introduced to the worldwide neurologic medical and surgical community. In that time, tremendous advances in computer software and hardware, as well as creative changes in computerized tomographic (CT) hardware and tube technology, have dramatically improved the temporal and spatial resolution of CT. In this paper, I address what I feel are some of the most important impacts of CT in the field of clinical neuroscience over the last 50 years, as well as potential applications of CT that are on the horizon. Approach: I have recounted from literature, colleagues, and personal recollection the historical impact of CT on neuroradiology practice and what appear to be near-term future applications. Conclusions: Therapeutic applications beyond diagnosis, such as image-guided procedures, radiation, and surgical planning, and development of the field of theranostics have emerged and further increased the need for faster and more precise CT imaging. The integration of machine learning into the acquisition chain and radiologist tool kit has great implications for standardization, analysis, and diagnosis worldwide.
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Affiliation(s)
- William P Dillon
- University of California, San Francisco, Department of Radiology and Biomedical Imaging, San Francisco, California, United States
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15
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Yanni DS, Ozgur BM, Louis RG, Shekhtman Y, Iyer RR, Boddapati V, Iyer A, Patel PD, Jani R, Cummock M, Herur-Raman A, Dang P, Goldstein IM, Brant-Zawadzki M, Steineke T, Lenke LG. Real-time navigation guidance with intraoperative CT imaging for pedicle screw placement using an augmented reality head-mounted display: a proof-of-concept study. Neurosurg Focus 2021; 51:E11. [PMID: 34333483 DOI: 10.3171/2021.5.focus21209] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Accepted: 05/17/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Augmented reality (AR) has the potential to improve the accuracy and efficiency of instrumentation placement in spinal fusion surgery, increasing patient safety and outcomes, optimizing ergonomics in the surgical suite, and ultimately lowering procedural costs. The authors sought to describe the use of a commercial prototype Spine AR platform (SpineAR) that provides a commercial AR head-mounted display (ARHMD) user interface for navigation-guided spine surgery incorporating real-time navigation images from intraoperative imaging with a 3D-reconstructed model in the surgeon's field of view, and to assess screw placement accuracy via this method. METHODS Pedicle screw placement accuracy was assessed and compared with literature-reported data of the freehand (FH) technique. Accuracy with SpineAR was also compared between participants of varying spine surgical experience. Eleven operators without prior experience with AR-assisted pedicle screw placement took part in the study: 5 attending neurosurgeons and 6 trainees (1 neurosurgical fellow, 1 senior orthopedic resident, 3 neurosurgical residents, and 1 medical student). Commercially available 3D-printed lumbar spine models were utilized as surrogates of human anatomy. Among the operators, a total of 192 screws were instrumented bilaterally from L2-5 using SpineAR in 24 lumbar spine models. All but one trainee also inserted 8 screws using the FH method. In addition to accuracy scoring using the Gertzbein-Robbins grading scale, axial trajectory was assessed, and user feedback on experience with SpineAR was collected. RESULTS Based on the Gertzbein-Robbins grading scale, the overall screw placement accuracy using SpineAR among all users was 98.4% (192 screws). Accuracy for attendings and trainees was 99.1% (112 screws) and 97.5% (80 screws), respectively. Accuracy rates were higher compared with literature-reported lumbar screw placement accuracy using FH for attendings (99.1% vs 94.32%; p = 0.0212) and all users (98.4% vs 94.32%; p = 0.0099). The percentage of total inserted screws with a minimum of 5° medial angulation was 100%. No differences were observed between attendings and trainees or between the two methods. User feedback on SpineAR was generally positive. CONCLUSIONS Screw placement was feasible and accurate using SpineAR, an ARHMD platform with real-time navigation guidance that provided a favorable surgeon-user experience.
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Affiliation(s)
- Daniel S Yanni
- 1Pickup Family Neurosciences Institute, Hoag Memorial Hospital Presbyterian Newport Beach; and.,2Disc Comfort, Inc., Newport Beach, California
| | - Burak M Ozgur
- 1Pickup Family Neurosciences Institute, Hoag Memorial Hospital Presbyterian Newport Beach; and
| | - Robert G Louis
- 1Pickup Family Neurosciences Institute, Hoag Memorial Hospital Presbyterian Newport Beach; and
| | - Yevgenia Shekhtman
- 3Neuroscience Institute, Hackensack Meridian JFK Medical Center, Edison; and
| | - Rajiv R Iyer
- 4Department of Orthopedic Surgery, Columbia University; and
| | | | - Asha Iyer
- 3Neuroscience Institute, Hackensack Meridian JFK Medical Center, Edison; and
| | - Purvee D Patel
- 5Department of Neurological Surgery, Rutgers New Jersey Medical School, Newark, New Jersey
| | - Raja Jani
- 5Department of Neurological Surgery, Rutgers New Jersey Medical School, Newark, New Jersey
| | - Matthew Cummock
- 5Department of Neurological Surgery, Rutgers New Jersey Medical School, Newark, New Jersey
| | - Aalap Herur-Raman
- 6George Washington University School of Medicine, Washington, DC; and
| | | | - Ira M Goldstein
- 5Department of Neurological Surgery, Rutgers New Jersey Medical School, Newark, New Jersey
| | - Michael Brant-Zawadzki
- 1Pickup Family Neurosciences Institute, Hoag Memorial Hospital Presbyterian Newport Beach; and
| | - Thomas Steineke
- 3Neuroscience Institute, Hackensack Meridian JFK Medical Center, Edison; and
| | - Lawrence G Lenke
- 4Department of Orthopedic Surgery, Columbia University; and.,8Department of Neurological Surgery, NewYork-Presbyterian/Allen Hospital, New York, New York
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16
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Shi C, Sun B, Tang G, Xu N, He H, Ye X, Xu G, Gu X. Clinical and radiological outcomes of endoscopic foraminoplasty and decompression assisted with preoperative planning software for lumbar foraminal stenosis. Int J Comput Assist Radiol Surg 2021; 16:1829-1839. [PMID: 34327630 DOI: 10.1007/s11548-021-02453-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2020] [Accepted: 07/06/2021] [Indexed: 10/20/2022]
Abstract
PURPOSE To assess the clinical and radiological outcomes of using endoscopic foraminoplasty and decompression assisted with a preoperative planning software in the treatment of lumbar foraminal stenosis. METHODS This retrospective study included 43 patients with lumbar foraminal stenosis (Jan 2018 and June 2019). These patients were divided into two groups. Patients in the conventional group (group A) underwent endoscopic lumbar foraminoplasty and decompression. Patients in the experimental group (group B) underwent the same surgery assisted with a preoperative software. The total operation time, puncture-channel establishment time, and the number of intraoperative fluoroscopic images taken were recorded. The Visual Analog Scale (VAS) and Oswestry Disability Index (ODI) were administered preoperatively and postoperatively (at 1-month, 3-month, and 12-month follow-up). The modified MacNab criteria were used to assess the global outcome at 12-month follow-up. RESULTS Patients in group B had shorter operation time, puncture-channel establishment time, and less number of intraoperative fluoroscopic images taken, as compared with group A. The VAS and ODI scores were significantly lower than pre-operation for both groups at all follow-ups. No significant difference was observed between these two groups. Based on the modified MacNab criteria, the excellent-to-good rate was 86.4% in group A and 90.5% in group B, respectively. After the operation, no patients had residual osteophytes in group B, while two patients still had residual osteophytes and foraminal stenosis in group A. CONCLUSION For endoscopic surgery treating lumbar foraminal stenosis, using preoperative planning software could reduce the puncture-channel establishment time, operation time, and the number of intraoperative fluoroscopic images taken without affecting the clinical outcomes.
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Affiliation(s)
- Changgui Shi
- Department of Spine Surgery, Changzheng Hospital, Second Military Medical University, 415 Fengyang Road, Shanghai, 200003, People's Republic of China
| | - Bin Sun
- Department of Spine Surgery, Changzheng Hospital, Second Military Medical University, 415 Fengyang Road, Shanghai, 200003, People's Republic of China
| | - Guoke Tang
- Department of Spine Surgery, Changzheng Hospital, Second Military Medical University, 415 Fengyang Road, Shanghai, 200003, People's Republic of China.,Department of Orthopedic Surgery, Tongren Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, People's Republic of China
| | - Ning Xu
- Department of Spine Surgery, Changzheng Hospital, Second Military Medical University, 415 Fengyang Road, Shanghai, 200003, People's Republic of China
| | - Hailong He
- Department of Spine Surgery, Changzheng Hospital, Second Military Medical University, 415 Fengyang Road, Shanghai, 200003, People's Republic of China
| | - Xiaojian Ye
- Department of Spine Surgery, Changzheng Hospital, Second Military Medical University, 415 Fengyang Road, Shanghai, 200003, People's Republic of China.,Department of Orthopedic Surgery, Tongren Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, People's Republic of China
| | - Guohua Xu
- Department of Spine Surgery, Changzheng Hospital, Second Military Medical University, 415 Fengyang Road, Shanghai, 200003, People's Republic of China.
| | - Xin Gu
- Department of Spine Surgery, Changzheng Hospital, Second Military Medical University, 415 Fengyang Road, Shanghai, 200003, People's Republic of China.
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Ozcamdalli M, Misir A, Oguzkaya S, Kizkapan TB, Turk OI, Uzun E. The effect of lumbar facet joint injection levels on spinopelvic parameters and functional outcome. J Back Musculoskelet Rehabil 2021; 34:103-109. [PMID: 33104017 DOI: 10.3233/bmr-200067] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Low back pain is a very common musculoskeletal complaint that impacts patients' quality of life in numerous ways. Facet joint injection is a widely used spinal intervention to relieve back pain. Effects of facet joint injection on spinopelvic parameters and the relationship between injection levels and spinopelvic parameter changes have not been evaluated before. OBJECTIVE To compare spinopelvic parameters before and after injections at different levels, and to evaluate the correlation between these changes and functional outcome. METHODS 144 patients were included in the study and retrospectively grouped by injection level: Group 1 (n= 72), L4-L5 and L5-S1, and group 2 (n= 72), L1-L2, L2-L3, L3-L4, L4-L5 and L5-S1. Pre- and post-injection Oswestry Disability Index (ODI), sacral slope, pelvic tilt, pelvic incidence, and intervertebral angles between T12 and S1 were compared. The correlation between ODI and radiographic parameter changes was evaluated. RESULTS The pre- to post-injection ODI change was significantly lower in group 2 (p= 0.010). There was no significant difference between the groups in terms of pre- and post-injection spinopelvic parameters before and after injection (p> 0.05) except pelvic tilt (p= 0.001 and p= 0.007, respectively). There was a significant moderate positive correlation between the change in the ODI value and the change in pelvic tilt (P= 0.012, r= 0.581). CONCLUSIONS Multilevel lumbar facet injections are clinically more effective than only two-level lower level lumbar injections. Pelvic tilt changes positively correlate with the ODI score changes.
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Affiliation(s)
- Mustafa Ozcamdalli
- Department of Orthopaedics and Traumatology, Ahi Evran University Faculty of Medicine, Kirsehir, Turkey
| | - Abdulhamit Misir
- Department of Orthopaedics and Traumatology, Gaziosmanpasa Training and Research Hospital, Health Sciences University, Istanbul, Turkey
| | - Sinan Oguzkaya
- Department of Orthopaedics and Traumatology, Sivas Sarkisla State Hospital, Sivas, Turkey
| | - Turan Bilge Kizkapan
- Department of Orthopaedics and Traumatology, Bursa Cekirge State Hospital, Bursa, Turkey
| | - Ozgur Ismail Turk
- Department of Orthopaedics and Traumatology, Sirnak Cizre State Hospital, Sirnak, Turkey
| | - Erdal Uzun
- Department of Orthopaedics and Traumatology, Faculty of Medicine, Erciyes University, Kayseri, Turkey
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18
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Cooley D, Bailey J, Jermyn R. Cost comparison of osteopathic manipulative treatment for patients with chronic low back pain. J Osteopath Med 2021; 121:635-642. [PMID: 33856751 DOI: 10.1515/jom-2020-0238] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Accepted: 02/04/2021] [Indexed: 11/15/2022]
Abstract
CONTEXT Chronic low back pain (cLBP) is the second leading cause of disability in the United States, with significant physical and financial implications. Development of a multifaceted treatment plan that is cost effective and optimizes patients' ability to function on a daily basis is critical. To date, there have been no published prospective studies comparing the cost of osteopathic manipulative treatment to that of standard care for patients with cLBP. OBJECTIVES To contrast the cost for standard of care treatment (SCT) for cLBP with standard of care plus osteopathic manipulative treatment (SCT + OMT). METHODS This prospective, observational study was conducted over the course of 4 months with two groups of patients with a diagnosis of cLBP. Once consent was obtained, patients were assigned to the SCT or the SCT + OMT group based on the specialty practice of their physician. At enrollment and after 4 months of treatment, all patients in both groups completed two questionnaires: the 11 point pain intensity numerical scale (PI-NRS) and the Roland Morris Disability Questionnaire (RMDQ). Cost data was collected from the electronic medical record of each patient enrolled in the study. Chi-square (χ 2 Yates) tests for independence using Yates' correction for continuity were performed to compare the results for each group. RESULTS There was a total of 146 patients: 71 (48.6%) in the SCT + OMT group and 75 (51.4%) in the SCT group. The results showed no significant differences between the mean total costs for the SCT + OMT ($831.48 ± $553.59) and SCT ($997.90 ± $1,053.22) groups. However, the utilization of interventional therapies (2; 2.8%) and radiology (4; 5.6%) services were significantly less for the SCT + OMT group than the utilization of interventional (31; 41.3%) and radiology (17; 22.7%) therapies were for the SCT group (p<0.001). Additionally, the patients in the SCT + OMT group were prescribed fewer opioid medications (15; 21.1) than the SCT (37; 49.3%) patients (p.001). Patients in the SCT group were approximately 14.7 times more likely to have received interventional therapies than patients in the SCT + OMT group. Likewise, the patients in the SCT group were approximately four times more likely to have received radiological services. Paired t tests comparing the mean pre- and 4 month self reported pain severity scores on the RMDQ for 68 SCT + OMT patients (9.91 ± 5.88 vs. 6.40 ± 5.24) and 66 SCT patients (11.44 ± 6.10 vs. 8.52 ± 6.14) found highly significant decreases in pain for both group (<0.001). CONCLUSIONS The mean total costs for the SCT and SCT + OMT patients were statistically comparable across 4 months of treatment. SCT + OMT was comparable to SCT alone in reducing pain and improving function in patients with chronic low back pain; however, there was less utilization of opioid analgesics, physical therapy, interventional therapies, radiologic, and diagnostic services for patients in the SCT + OMT group.
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Affiliation(s)
- Danielle Cooley
- Department of Osteosciences, Neuromusculoskeletal Institute, Rowan University School of Osteopathic Medicine, Stratford, NJ, USA
| | - James Bailey
- Department of Osteosciences, Neuromusculoskeletal Institute, Rowan University School of Osteopathic Medicine, Stratford, NJ, USA.,Department of Physical Medicine and Rehabilitation, Rowan University School of Osteopathic Medicine, Stratford, NJ, USA
| | - Richard Jermyn
- Department of Physical Medicine and Rehabilitation, Rowan University School of Osteopathic Medicine, Stratford, NJ, USA
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Mendonça RDH, Fernandes HDS, Pinto RBS, Matsui Júnior C, Polido GJ, Silva AMSD, Grossklauss LF, Reed UC, Zanoteli E. Managing intrathecal administration of nusinersen in adolescents and adults with 5q-spinal muscular atrophy and previous spinal surgery. ARQUIVOS DE NEURO-PSIQUIATRIA 2021; 79:127-132. [PMID: 33759979 DOI: 10.1590/0004-282x-anp-2020-0200] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Accepted: 07/05/2020] [Indexed: 11/21/2022]
Abstract
BACKGROUND Spinal muscular atrophy (SMA) is a neurodegenerative disease of lower motor neurons associated with frequent occurrence of spinal deformity. Nusinersen is an antisense oligonucleotide that increases SMN protein level and is administrated by frequent intrathecal lumbar injections. Thus, spinal deformities and previous spinal surgery are important challenges for drug delivery in SMA. OBJECTIVE To report imaging methods used for Nusinersen injection in SMA patients. METHODS Nusinersen injection procedures in SMA types 2 and 3 patients who had previous spinal surgery were analyzed retrospectively to describe the imaging and puncture procedures, as well as the occurrence of complications. RESULTS Nine SMA patients (14 to 50 years old) underwent 57 lumbar punctures for nusinersen injection. Six patients had no interlaminar space available; in five of them, a transforaminal approach was used, and another one underwent a surgery to open a posterior bone window for the injections. Transforaminal puncture was performed using CT scan in three cases and fluoroscopy in the other two, with a similar success rate. One patient in the transforaminal group had post-procedure radiculitis, and another one had vagal reaction (hypotension). In three cases, with preserved interlaminar space, injections were performed by posterior interlaminar puncture, and only one adverse event was reported (post-puncture headache). CONCLUSION In SMA patients with previous spinal surgery, the use of imaging-guided intervention is necessary for administering intrathecal nusinersen. Transforaminal technique is indicated in patients for whom the interlaminar space is not available, and injections should always be guided by either CT or fluoroscopy.
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Affiliation(s)
| | | | | | - Ciro Matsui Júnior
- Universidade de São Paulo, Faculdade de Medicina, Departamento de Neurologia, São Paulo SP, Brazil
| | - Graziela Jorge Polido
- Universidade de São Paulo, Faculdade de Medicina, Departamento de Neurologia, São Paulo SP, Brazil
| | | | - Luis Fernando Grossklauss
- Universidade Federal de São Paulo, Departamento de Neurologia, Divisão Neuromusculares, São Paulo SP, Brazil
| | - Umbertina Conti Reed
- Universidade de São Paulo, Faculdade de Medicina, Departamento de Neurologia, São Paulo SP, Brazil
| | - Edmar Zanoteli
- Universidade de São Paulo, Faculdade de Medicina, Departamento de Neurologia, São Paulo SP, Brazil
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20
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Tiegs-Heiden CA, Murthy NS, Geske JR, Diehn FE, Lehman VT, Liebo GB, Verdoorn JT, Carr CM, McKenzie GA. Impact of flow pattern, body mass index, and age on intraprocedural fluoroscopic time and radiation dose during sacroiliac joint injections. Neuroradiol J 2021; 34:428-434. [PMID: 33685248 DOI: 10.1177/1971400921998966] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
PURPOSE Understanding all factors that may impact radiation dose and procedural time is crucial to safe and efficient image-guided interventions, such as fluoroscopically guided sacroiliac (SI) joint injections. The purpose of this study was to evaluate the effect of flow pattern (intra- vs. periarticular), patient age, and body mass index (BMI) on radiation dose and fluoroscopy time. METHODS A total of 134 SI joint injections were reviewed. Injectate flow pattern, age, and BMI were analyzed in respect to fluoroscopy time (minutes), radiation dose (kerma area product (KAP); µGy m2), and estimated skin dose (mGy). RESULTS BMI did not affect fluoroscopy time, but increased BMI resulted in significantly higher skin and fluoroscopy doses (p < 0.001). There was no association between fluoroscopy time and flow pattern. Higher skin dose was associated with intraarticular flow (p = 0.0086), and higher KAP was associated with periarticular flow (p = 0.0128). However, the odds ratios were close to 1. There was no significant difference between fluoroscopy time or dose based on patient age. CONCLUSION Increased BMI had the largest impact on procedural radiation dose and skin dose. Flow pattern also showed a statistically significant association with radiation dose and skin dose, but the clinical difference was small. Proceduralists should be aware that BMI has the greatest impact on fluoroscopy dose and skin dose during SI joint injections compared to other factors.
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Affiliation(s)
| | | | - Jennifer R Geske
- Department of Biomedical Statistics and Informatics, Mayo Clinic, USA
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21
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Iwayama H, Wakao N, Kurahashi H, Kubota N, Hattori A, Kumagai T, Okumura A. Administration of nusinersen via paramedian approach for spinal muscular atrophy. Brain Dev 2021; 43:121-126. [PMID: 32773161 DOI: 10.1016/j.braindev.2020.07.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Revised: 07/07/2020] [Accepted: 07/21/2020] [Indexed: 10/23/2022]
Abstract
OBJECTIVE To assess the success rate, procedure time, and adverse events of intrathecal administration of nusinersen via the paramedian approach in adolescents and adults with spinal muscular atrophy (SMA) associated with scoliosis. METHODS Seven patients with genetically confirmed SMA (age, 12-40 years) were included. Intrathecal administration of nusinersen was performed via paramedian approach using fluoroscopy after determination of the largest interlaminal foramen among L2-L3, L3-L4, or L4-L5 by three-dimensional computed tomography. We measured the times for preparation, positioning, and puncture, and the total time of stay. Adverse effects of intrathecal administration were noted. RESULTS Intrathecal administration via paramedian approach was successful for all 38 opportunities. The median total time of stay was 44.0 min (interquartile range, 37.3-50.0 min). The total time of stay was significantly longer in patients with SMA type 1 than in those with SMA type 2, but was not different according to the severity of scoliosis. Adverse effects included oxygen supplementation, headache, and back pain. Sedation was correlated with oxygen supplementation and headache. CONCLUSIONS Intrathecal administration of nusinersen via the paramedian approach had the advantages of a high success rate and short procedure time with fewer adverse events in SMA patients associated with scoliosis.
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Affiliation(s)
- Hideyuki Iwayama
- Department of Pediatrics, Aichi Medical University, Aichi, Japan.
| | - Norimitsu Wakao
- Department of Orthopedics, Aichi Medical University, Aichi, Japan
| | - Hirokazu Kurahashi
- Department of Pediatrics, Aichi Medical University, Aichi, Japan; Department of Pediatric Neurology, Aichi Prefectural Colony Central Hospital, Aichi, Japan
| | - Norika Kubota
- Department of Pediatrics, Matsue Medical Center, Shimane, Japan
| | - Ayako Hattori
- Department of Pediatrics and Neonatology, Nagoya City University, Aichi, Japan
| | - Toshiyuki Kumagai
- Department of Pediatric Neurology, Aichi Prefectural Colony Central Hospital, Aichi, Japan; Kuma Home Medical Care Clinic, Aichi, Japan
| | - Akihisa Okumura
- Department of Pediatrics, Aichi Medical University, Aichi, Japan
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Gibby J, Cvetko S, Javan R, Parr R, Gibby W. Use of augmented reality for image-guided spine procedures. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2020; 29:1823-1832. [DOI: 10.1007/s00586-020-06495-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/22/2019] [Revised: 04/07/2020] [Accepted: 05/31/2020] [Indexed: 12/14/2022]
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Ott FW, Pluhm R, Ozturk K, McKinney AM, Rykken JB. Counterpoint: Conventional Fluoroscopy-Guided Selective Cervical Nerve Root Block-A Safe, Effective, and Efficient Modality in the Hands of an Experienced Proceduralist. AJNR Am J Neuroradiol 2020; 41:1112-1119. [PMID: 32522840 DOI: 10.3174/ajnr.a6580] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Accepted: 04/07/2020] [Indexed: 01/21/2023]
Abstract
BACKGROUND AND PURPOSE The conventional fluoroscopy-guided (CF) selective cervical nerve root block (SCNRB) is being used commonly as a treatment for cervical radicular pain as well as a diagnostic tool. This study aimed to identify any major complications and determine the safety and clinical utility of CF-SCNRB performed in a university hospital and associated outpatient clinics. MATERIALS AND METHODS Two-hundred fifty-four conventional fluoroscopy-guided selective cervical nerve root blocks were retrospectively identified from 2011 to 2018 using a radiology report search tool. Each procedure was performed by an experienced neuroradiologist performing spinal injections on a full-time basis in clinical practice. A 10-point pain scale was used for pre- and postprocedural pain-level assessment. Successful conventional, fluoroscopy-guided, selective cervical nerve root block was defined as a patient-reported pain scale reduction of at least 50% and/or alleviation of numbness or paresthesia at ≥2 weeks postinjection. All clinically important immediate and delayed complications were also recorded. RESULTS Two-hundred fifty-four conventional fluoroscopy-guided selective cervical nerve root blocks were performed via an anterolateral approach with an average fluoroscopy time of 24.3 seconds for all cases. There were no aborted procedures and no major or permanent complications. There were 14 minor complications; 12 of these were periprocedural and resolved by the 2-week follow-up visit. One-hundred eighty-five patients (75.2%) reported pain improvement of >50% from baseline at 15 minutes postinjection. Overall, 172 patients (67.7%) reported >50% pain scale reduction or alleviation from paresthesia at least 2 weeks postinjection. CONCLUSIONS Conventional fluoroscopy-guided selective cervical nerve root block is an efficacious, efficient, and safe outpatient procedure when performed by a skilled and experienced proceduralist.
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Affiliation(s)
- F W Ott
- From the Department of Radiology, University of Minnesota, Minneapolis, Minnesota.
| | - R Pluhm
- From the Department of Radiology, University of Minnesota, Minneapolis, Minnesota
| | - K Ozturk
- From the Department of Radiology, University of Minnesota, Minneapolis, Minnesota
| | - A M McKinney
- From the Department of Radiology, University of Minnesota, Minneapolis, Minnesota
| | - J B Rykken
- From the Department of Radiology, University of Minnesota, Minneapolis, Minnesota
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Long JR, Stensby JD, Wiesner EL, Bryson WN, Hillen TJ, Jennings JW. Efficacy and safety of bone marrow aspiration and biopsy using fluoroscopic guidance and a drill-powered needle: clinical experience from 775 cases. Eur Radiol 2020; 30:5964-5970. [PMID: 32518988 DOI: 10.1007/s00330-020-06987-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Revised: 04/17/2020] [Accepted: 05/27/2020] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To evaluate the efficacy and safety of performing a fluoroscopically guided bone marrow aspiration and biopsy (BMAB) using a drill-powered needle in a large patient population. METHODS This retrospective study received institutional review board approval with a waiver of patient informed consent. We identified all BMAB procedures from August 2012 through December 2016 performed at our institution using fluoroscopic guidance and a drill-powered needle. Clinical diagnosis, patient age, patient gender, biopsy site, biopsy needle gauge, bone marrow aspirate volume, bone marrow core biopsy length, patient platelet count, conscious sedation details, complications, and diagnostic adequacy were investigated for each case and summarized. RESULTS A total of 775 BMAB procedures were performed and analyzed. These were performed in 436 female patients and 339 male patients ranging in age between 16 and 91 years (average age of 53 years). Samples obtained from the procedures in our series were diagnostic in 95.0% of cases. The complication rate for our series was 0.3%. CONCLUSIONS The use of fluoroscopic guidance and a drill-powered needle for bone marrow aspiration and biopsy is a safe and efficacious procedure. KEY POINTS • Fluoroscopy can be utilized for imaging guidance during bone marrow aspiration and biopsy. • The use of fluoroscopic guidance and a drill-powered needle for bone marrow aspiration and biopsy has a high diagnostic yield. • The procedure has an excellent patient safety profile.
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Affiliation(s)
- Jeremiah R Long
- Mayo Clinic Arizona, 5777 East Mayo Boulevard, Phoenix, AZ, 85054, USA.
| | - J Derek Stensby
- University of Missouri, One Hospital Drive, Columbia, MO, 65212, USA
| | - Elizabeth L Wiesner
- Mallinckrodt Institute of Radiology, Washington University in St. Louis, 510 South Kingshighway Boulevard, St. Louis, MO, 63110, USA
| | - Wesley N Bryson
- Mallinckrodt Institute of Radiology, Washington University in St. Louis, 510 South Kingshighway Boulevard, St. Louis, MO, 63110, USA
| | - Travis J Hillen
- Mallinckrodt Institute of Radiology, Washington University in St. Louis, 510 South Kingshighway Boulevard, St. Louis, MO, 63110, USA
| | - Jack W Jennings
- Mallinckrodt Institute of Radiology, Washington University in St. Louis, 510 South Kingshighway Boulevard, St. Louis, MO, 63110, USA
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Castle-Kirszbaum M, Maingard J, Goldschlager T, Chandra RV. Preoperative coil localization for spinal surgery: technical note. J Neurosurg Spine 2020; 32:483-487. [PMID: 31731276 DOI: 10.3171/2019.8.spine19762] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2019] [Accepted: 08/28/2019] [Indexed: 11/06/2022]
Abstract
Intraoperative localization in spinal surgery is essential to facilitate the best surgical outcome and to avoid wrong-site surgery. Intraoperative fluoroscopy is generally adequate, but anatomical variation, body habitus, and the inherent difficulties of fluoroscopy at certain levels may lead the surgeon astray. Here, the authors present their technique for preoperative localization that relies solely on fixed anatomical landmarks using CT-guided, percutaneously placed radiopaque markers. In the outpatient setting, low-dose CT scanning of the neuraxis is performed to identify fixed landmarks and, under local anesthesia and CT guidance, a pushable microcoil is inserted through a Chiba needle into the periosteum of the pedicle at the level of interest. The patient returns home with no precautions while the coil is in situ, and then the patient returns sometime later for surgery. Intraoperatively, typically a single lateral radiograph is required to visualize the coil and the level. Preoperative placement of radiopaque markers at the level of interest is an effective tool for avoiding wrong-site surgery, especially in circumstances in which fluoroscopy may be troublesome. The authors' method is accurate, effective, and expeditious and can be performed easily in the outpatient setting.
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Affiliation(s)
| | - Julian Maingard
- 2Neurointerventional Radiology Unit, Monash Imaging, Monash Health, Melbourne; and
| | - Tony Goldschlager
- 1Department of Neurosurgery and
- 3Department of Surgery, Monash University, Melbourne, Australia
| | - Ronil V Chandra
- 2Neurointerventional Radiology Unit, Monash Imaging, Monash Health, Melbourne; and
- 3Department of Surgery, Monash University, Melbourne, Australia
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Radiation dose reduction for CT-guided intrathecal nusinersen administration in adult patients with spinal muscular atrophy. Sci Rep 2020; 10:3406. [PMID: 32099042 PMCID: PMC7042284 DOI: 10.1038/s41598-020-60240-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Accepted: 01/24/2020] [Indexed: 12/18/2022] Open
Abstract
Intrathecal administration of nusinersen in adult spinal muscular atrophy (SMA) patients with scoliosis and spondylodesis requires image guidance, which is preferably achieved with multi-detector computed tomography (MDCT). As long-term treatment is necessary and patients are young, radiation doses should be reduced to a minimum whilst a sufficient image quality for precise interventional performance should be kept. We compared 44 MDCT standard-dose scans (133.0–200.0 mA) with a hybrid iterative reconstruction (iDose4) to 20 low-dose scans (20.0–67.0 mA) with iterative model reconstruction (IMR), which were performed for procedure planning of intrathecal nusinersen administration in 13 adult patients with SMA and complex spinal conditions. Qualitative image evaluation, including confidence for intervention planning, was performed by two neuroradiologists for standard- and low-dose scans. All 64 MDCT-guided intrathecal administrations of nusinersen were successful. The dose length product (DLP) was significantly lower when using low-dose scanning with IMR (median DLP of standard-dose scans: 92.0 mGy•cm vs. low-dose scans: 34.5 mGy•cm; p < 0.0001). Image quality was significantly reduced for low-dose compared to standard-dose scanning. However, bone/soft tissue contrast and confidence for intervention planning were not significantly impaired in low-dose MDCT according to both readers, showing good inter-reader agreement. Thus, we hereby demonstrate a low-dose MDCT protocol combined with advanced image reconstruction for scanning during procedure planning as a viable option for image guidance in intrathecal nusinersen treatment of adult SMA patients with complex spinal conditions.
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Systematic Evaluation of Low-dose MDCT for Planning Purposes of Lumbosacral Periradicular Infiltrations. Clin Neuroradiol 2019; 30:749-759. [DOI: 10.1007/s00062-019-00844-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2019] [Accepted: 10/04/2019] [Indexed: 12/16/2022]
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