1. Does Fibronectin Aggrecan Complex Predict Response to Epidural Steroid Injection? Lisa Huynh MD Matthew Smuck MD, Agnes Martinez-Ith, David J. Kennedy MD Department of Orthopaedic Surgery, PM&R Section, Stanford University, Redwood City, CA AAPM&R Annual Assembly November 16, 2014

2. DISCLOSURES Lisa Huynh, MD Nothing to disclose Matthew Smuck, MD Cytonics Corporation (Research Support) North American Spine Society (Travel, Honoraria) The Spine Journal (Executive Editorial Board) Agnes Martinez-Ith Cytonics Corporation (Research Support) David J. Kennedy, MD Cytonics Corporation (Research Support) North American Spine Society (Travel, Honoraria) PM&R (Editorial Board)

3. BACKGROUND Extensive research on degenerative disc disease, yet much remains to be learned Radicular pain secondary to mechanical compression and inflammatory pathways ESI is an effective treatment for lumbar radicular pain, but only in a proportion of patients 1 Need a reliable approach to determine good candidates for ESIs Not without risk Cost containment 1. Ghahreman A, Ferch R, Bogduk N. The efficacy of transforaminal injection of steroids for the treatment of lumbar radicular pain. Pain Med 2010;11:1149-1168

4. BACKGROUND Inflammatory cytokines and protein biomarkers are being studied as diagnostic indicators and potential therapeutic targets 1 Elevated levels of metallomatrix proteases, nitric oxide, prostaglandin-E, (IL)-6, (TNF)- α, amongst others have been implicated in disk degeneration 2,3 1. Golish SR, Hanna LS, Bowser RP, et al. Outcome of lumbar epidural steroid injection is predicted by assay of a complex of fibronectin and aggrecan from epidural lavage. Spine 2011;36:1464-9. 2. Kang JD, Georgescu HI, McIntyre-Larkin L, et al. Herniated lumbar intervertebral discs spontaneously produce matrix metalloproteinases, nitric oxide, interleukin-6, and prostaglandin E2. Spine 1996;21:271-2. 3. Kobayashi S, Baba H. Uchida K, et al. Effect of mechanical compression on the lumbar nerve root: localization and change of intraradicular inflammatory cytokines, nitric oxide, and cyclooxygenase. Spine 2005;30:1699-705

5. BACKGROUND Fibronectin Large extracellular glycoprotein Contains a number of domains to bind various ligands including fibrin, collagen, glycosaminoglycans, and various cytokines 1 Ability to cleave aggrecan 2 Aggrecan Major proteoglycan in extra-cellular matrix component of articular cartilage 3 1. Potts JR, Campbell ID. Structure and function of fibronectin molecules. Matrix Biol 1996;15(5):313-20. 2. Homandberg GA, Davis G, Maniglia C, et al. Cartilage chondrolysis by firbonectin fragments causes clevage of aggrecan at the same site as found in osteoarthritic cartilage. Osteoarthr Cartil 1997;5(6):450-453. 3. Abrams GD, Safran MR, Shapiro LM, et al. Fibronectin-aggrecan complex as a marker for cartilage degradation in non-arthritic hips. Knee Surg Sports Traumatol Arthrosc 2014;22(4):768-73

6. BACKGROUND Fragmentation of fibronectin and aggrecan seen in degenerative joint conditions and articular cartilage damage 1 May facilitate signaling of inflammatory cascade Fibronectin-aggrecan complex (FAC) shown to be associated with inflammation and pain in degenerative joint and spine conditions 1,2 FAC predicts response to lumbar ESI for radiculopathy with HNP Single-center, prospective, consecutive case series of 27 patients underwent epidural lavage prior to ESI Primary outcome: PCS (of SF-36) >4.9 Presence of FAC predicted clinically significant improvement in PCS after lumbar ESI 1.Scuderi GJ, Golish SR, Cook FF, et al. Identification of a novel fibronectin-aggrecan complex in the synovial fluid of knees with painful meniscal injury. J Bone Joint Surg Am 2011;93:336-40. 2.Gajendran VK, Reuter M, Golish SR, et al. The fibronectin-aggrecan complex: Is it present in cervical disc disease? Phys Med Rehab 2011;3:1030-4. 3.Golish SR, Hanna LS, Bowser RP, Montesano PX, Carragee EJ, Scuderi GJ. Outcome of lumbar epidural steroid injection is predicted by assay of a complex of fibronectin and aggrecan from epidural lavage. Spine (Phila Pa 1976). 2011 Aug 15;36(18):1464-9.

7. PURPOSE To investigate the fibronectin-aggrecan G3 domain complex (FAC) as a biomarker to predict response to epidural steroid injections in patients with lumbar disc herniations

8. METHODS Study Design Prospective, consecutive cohort study at a university spine center Patient Sample Target: 100 patients Screened consecutive patients scheduled for ESI Inclusion: lumbar radicular pain positive physical exam findings positive straight leg raise and/or diminished patellar or Achilles tendon reflex MRI confirmed disc herniation Exclusion: negative lumbar MRI ESI in previous 3 months presence of any red flags minors, pregnant, prisoners, not competent to make decisions

9. METHODS Using fluoroscopic guidance, performed physiologic saline epidural lavage Lavage sample collected prior to steroid administration ELISA analysis to detect FAC FAC positive if optical density was >0.06 at 450nm 1.Scuderi GJ, Cuellar JM, Cuellar VG, Yeomans DC, Carragee EJ, Angst MS. Epidural interferon gamma-immunoreactivity: a biomarker for lumbar nerve root irritation. Spine (Phila Pa 1976). 2009 Oct 1;34(21):2311-7. 2.Golish SR, Hanna LS, Bowser RP, Montesano PX, Carragee EJ, Scuderi GJ. Outcome of lumbar epidural steroid injection is predicted by assay of a complex of fibronectin and aggrecan from epidural lavage. Spine (Phila Pa 1976). 2011 Aug 15;36(18):1464-9.

10. METHODS Outcomes Measures Oswestry Disability Index (ODI) and Numeric Pain Rating Scale (NPRS) assessed at baseline and 6 weeks post-ESI Criteria for success: ”Responders”: ODI improvement of 15 points, AND NPRS reduction of 30% “Nonresponders” All remaining participants

11. METHODS Analysis Differences between group means evaluated using independent samples t-tests and two-by-two contingency table analysis.

12. Results Target N = 100 Screened N = 387 Enrolled N = 63 2 insufficient lavage samples 1 discontinued from hypotension Age: 20-70 (mean 42.57 years) Sex: 55.6% males, 44.4% females

13. RESULTS

14. Sensitivity 26.7% (95% CI: 8-55.1%) Specificity 91.1% (95%CI: 78.8%-97.5%) p < 0.0982 Presence of FAC in Responders and Nonresponder Groups to ESI Oswestry Disability Index and Numeric Pain Rating Scale at 6 weeks Responders to ESINonresponders to ESI FAC Positive44 FAC Negative1141 Primary Outcome

15. RESULTS Oswestry Disability Index Only at 6 weeks Presence of FAC in those with >15 point ODI improvement versus those without Responders to ESINonresponders to ESI FAC Positive80 FAC Negative1339 Sensitivity 38.1% (95% CI: 18.2-61.6%) Specificity 100% (95% CI: 90.9-100%) p <0.0001

16. DISCUSSION Greater improvement in NPRS and ODI at 6 weeks in the FAC (+) group compared to FAC (-) group Presence of FAC in disc samples from patients with radiculopathy is associated with improvement in disability following ESI FAC has a role in predicting response to ESIs

17. DISCUSSION Limitations Amount of lavage fluid sample was variable Study was underpowered Invasive sampling method with inherent risks which may limit diagnostic potential Further studies needed to elucidate roles of inflammatory markers

18. CONCLUSION FAC status predicts disability, but not pain outcomes 6-weeks after ESI in patients with lumbar disc herniations.

19. Thank You! Lisa Huynh, MD Interventional Spine Fellow Department of Orthopaedic Surgery, PM&R Division Stanford University Stanford University Spine Center