1. What will help my practice? David E. Fish, MD, MPH Professor, Department of Orthopaedics Physical Medicine and Rehabilitation, The UCLA Spine Center UCLA School of Medicine AAPM&R Best Pain and Spine Papers

2. David E. Fish, MD, MPH Physical Medicine and Rehabilitation Department of Orthopeadic Surgery

3. Influence Of Low Back Pain And Prognostic Value Of MRI In Sciatica Patients In Relation To Back Pain

4. Study # 1 Influence of low back pain and prognostic value of MRI in sciatica patients in relation to back pain. el Barzouhi A PLoS One. 2014 Mar 17;9(3):e90800. doi: 10.1371/journal.pone.0090800. eCollection 2014.

6. Purpose It is not known whether there are prognostic relevant differences in Magnetic Resonance Imaging (MRI) findings between sciatica patients with and without disabling back pain.

7. Methods The MRI findings were compared between sciatica patients with and without disabling back pain Two neuroradiologists and one neurosurgeon independently evaluated all MR images. The presence of disabling back pain at baseline was correlated with perceived recovery at one year.

8. Results 379 sciatica patients, 158 (42%) had disabling back pain.. Of the patients with both sciatica and disabling back pain 68% did reveal a herniated disc with nerve root compression on MRI.

9. Results The existence of disabling back pain in sciatica at baseline was negatively associated with perceived recovery at one year (Odds ratio [OR] 0.32 95% Confidence Interval 0.18-0.56, P<0.001).

10. Results Sciatica patients with disabling back pain in absence of nerve root compression on MRI at baseline reported less perceived recovery at one year compared to those with predominantly sciatica and nerve root compression on MRI. (50% vs 91%, P<0.001)

11. Is this good science? Hells Yeah it is!!!

12. Is it important to PMR? Without a doubt !!!

14. How will it change me and my practice with patients? You can’t judge a person’s emotional state with perceived pain and what is seen on an MRI. One must methodically go through the work up and conservative treatment Give a person time to recover with therapy, medications, epidurals, and time. Have the surgical option for a neurological deficit. Consider more psychological screening and treatment in an individual with a ‘normal’ MRI.

15. PAIN AS A DISEASE

16. Diagnostic Accuracy Of History Taking To Assess Lumbosacral Nerve Root Compression

17. Study # 2 Diagnostic accuracy of history taking to assess lumbosacral nerve root compression Verwoerd AJ Spine J. 2014 Sep 1;14(9):2028- 37. doi: 10.1016/j.spinee.2013.11.049. Epub 2013 Dec 8.

18. Purpose To assess the diagnostic accuracy of history taking for the presence of lumbosacral nerve root compression or disc herniation on magnetic resonance imaging in patients with sciatica.

19. Methods 395 adult patients with severe disabling radicular leg pain of 6 to 12 weeks duration were included History was broken out to a standardized protocol of 20 questions to find what contributed in diagnosing nerve root compression Examples: "male sex," "pain worse in leg than in back," "a non-sudden onset." "body mass index <30," "sensory loss."

20. Methods Age > 40 years Male sex BMI >30 Intellectual job Physically heavy job Smoking Duration of pain for > 9 weeks Leg pain duration in weeks Pain worse in leg than back Back pain > 12 weeks Sudden Onset Previous leg pain Subjective sensory loss Subjective muscle weakness

21. Results

22. Conclusion Few history items used in isolation have a diagnostic value to predict MRI disk herniation and nerve root compression. Diagnostic accuracy of history taking is limited. The evidence to base diagnostic history and physical exam with sciatica remains limited

23. Is this good science? Unfortunately.

24. Is it important to PMR? Absolutely

26. How will it change me and my practice with patients? You got me…

27. Thoracic interlaminar epidural injections in managing chronic thoracic pain: a randomized, double-blind, controlled trial with a 2-year follow-up.

28. Study # 3 Manchikanti L Pain Physician. 2014 May- Jun;17(3):E327-38.

29. Background The prevalence of thoracic pain in approximately 13% of the general population compared to 32% of the population with neck pain and 43% of the population with low back pain Interventions in managing chronic thoracic pain are also less frequent, leading to the paucity of literature about various interventions in managing chronic thoracic pain

30. Purpose Assess the effectiveness of thoracic interlaminar epidural injections in providing effective pain relief and improving function in patients with chronic mid and/or upper back pain.

31. Methods A randomized, double-blind, active controlled trial. 110 participants divided into 2 groups 1. 1.ESI with local anesthetic alone 2. 2.ESI with steroid (Bethamethasone 6mg)

32. Outcome Measures Oswestry Disability Index Employment status Opioid Intake (morphine equivalents) Greater than 3 weeks of ‘significant’ improvement with first 2 procedures were considered success Significant = > 50% decrease in scores at 3, 6, 12, 18, and 24 months

33. Methods Inclusion Criteria no facet joint pain based on blocks 18 years or older pain duration for more than 6 months failed conservative care Exclusion Criteria facet joint pain unstable or uncontrolled opioid use uncontrolled psychiatric issues uncontrolled medial illness large disc herniation with spinal cord compression active infection

34. Methods Injection done as an interlaminar approach facet blocks done to determine pain generator sedation for the injection pain complaint pattern with clinical and imaging repeated ESI only when pain increased The level of success reduced to below 50%

35. Results Groups 1 and 2 : 71% and 81% significantly improved 2 year follow up Characteristics 5 to 6 ESI over 2 years Relief in weeks Group 1: 80 weeks Group 2: 78 weeks

36. Results ESI levels T9-T1030% T10-T1131% T8-T917% Others 6%

37. Results

38. Results

39. Is this good science? I don’t know… I must be doing something wrong doing something wrong based on these results… based on these results…

40. Is This Good Science? High success rate Significant number of opiate reductions I don’t see that much thoracic pain No indication of compression fractures The steroid group did as well as local only

41. Is This Good Science? Authors admit that mechanism of efficacy is unclear. Authors indicate that the results are similar to cervical and lumbar result in literature The success is based on first two injections and if no success, ESI were not continued. No Placebo group… is local a placebo?

42. Is it important to PMR? Definitely because I am inadequate.

43. Transforaminal Thoracic

44. How will it change me and my practice with patients? I may stop doing bilateral TFESI I may stop using steroids. I am sending all patients to Kentucky for shots! I am sending all patients to Kentucky for shots!

45. Does the presence of the fibronectin- aggrecan complex predict outcomes from lumbar discectomy for disc herniation?

46. Study # 4 Does the presence of the fibronectin-aggrecan complex predict outcomes from lumbar discectomy for disc herniation? Smith MW Spine J. 2013 Nov 13. pii: S1529- 9430(13)00767-5. doi: 10.1016/j.spinee.2013.06.064.

47. Background Protein biomarkers associated with lumbar disc disease have been studied as diagnostic indicators and therapeutic targets. A cartilage degradation product, the fibronectin-aggrecan complex (FAC) identified in the epidural space, has been shown to predict response to lumbar epidural steroid injection.

48. Background Protein biomarkers associated with lumbar disc disease have been studied as diagnostic indicators and therapeutic targets. Numerous disease-modifying therapies have been proposed to intervene in this cascade, including antibody therapies, stem cell and cellular therapies, and gene therapies

49. Background A complex molecular and cellular cascade of disc degeneration has been elucidated, which involves inflammatory mediators cytokines, nitric oxide, and signal transduction pathways structural proteins and their degradation fragments (e.g., fibronectin, aggrecan, and collagens) proteases/protease inhibitors (e.g., matrix metalloproteinases [MMPs] and aggrecanases).1–6

50. Purpose Determine the ability of FAC to predict response to microdiscectomy for patients with radiculopathy due to lumbar disc herniation

51. Methods Intraoperative sampling was done via lavage of the excised fragment by ELISA for presence of FAC. 92 consecutive patients who opted for microdiscectomy to treat lumbar or lumbosacral radiculopathy caused by a lumbar 92 consecutive patients who opted for microdiscectomy to treat lumbar or lumbosacral radiculopathy caused by a lumbar disc herniation.

52. Methods excluded criteria: excluded criteria: plain radiography demonstrating severe loss of disc height high-grade degenerative disc disease spondylolisthesis greater than grade I Prior lumbar surgery or trauma physical examination revealing weakness in a distribution inconsistent with the MRI Diagnosis of inflammatory arthritides crystalline arthropathies or other rheumatologic diseases red flags: progressive weakness bowel or bladder complaints unknown radiographic mass unexpected weight loss

53. Results 75 individuals At 3-month follow-up, 57 (76%) patents were "better." There was a statistically significant association of the presence of FAC and clinical improvement (p=.017) with an 85% positive predictive value.

54. Results

55. Conclusions Patients who are "FAC+" are more likely to demonstrate clinical improvement following microdiscectomy. The data suggest that the inflammatory milieu plays a significant role regarding improvement in patients undergoing discectomy for radiculopathy in lumbar HNP The FAC represents a potential target for treatment in HNP.

56. Is this good science? Maybe… The results of the subset analysis suggest that patients with preoperative weakness have a very strong association between presence of FAC and clinical improvement. This is an intriguing finding that the removal of the inflammatory component may be more related to outcomes, not necessarily the mechanical compression. (Chemical Radiculitis)

57. Is it important to PMR? For Spine specialists it maybe the reason why patients don’t respond to injections.

58. How will it change me and my practice with patients? Do we do assays on all patients for presence of FAC? The relative contribution of inflammatory processes versus mechanical processes is evolving

59. Outcomes of Fluoroscopically Guided Lumbar Transforaminal Epidural Steroid Injections in Degenerative Lumbar Spondylolisthesis Patients Outcomes of Fluoroscopically Guided Lumbar Transforaminal Epidural Steroid Injections in Degenerative Lumbar Spondylolisthesis Patients

60. Study # 5 Outcomes of Fluoroscopically Guided Lumbar Transforaminal Epidural Steroid Injections in Degenerative Lumbar Spondylolisthesis Patients Kraiwattanapong, C Asian Spine J 2014;8(2):119-128 http://dx.doi.org/10.4184/asj.2014.8.2.119.

61. Background Fluoroscopically guided TFESI is frequently being used for treatment of radicular pains in lumbar disc herniation, spinal stenosis and degenerative disc disease patients with various results. There has been no study which has exclusively evaluated the effectiveness of epidural steroid injections in patients with Degenerative Lumbar Spondylolisthesis (DLS).

62. Purpose Report the short- and long-term outcomes of fluoroscopically guided lumbar TFESI in DLS patients.

63. Methods 38 DLS patients who underwent fluoroscopically guided lumbar TFESI during April 2009 to March 2010

64. Methods 22 gauge spinal needles at spondylolisthesis level 1% lidocaine 2mls Depomedrol 80mg

65. Methods Inclusion criteria Inclusion criteria 1)Patients with history of low back pain and unilateral radiating pain at least below the knee joint 2)Patients with slip grade 1 degenerative lumbar spondylolisthesis, visible on plain radiographs and one or two levels of neural compression found from the magnetic resonance imaging (MRI) 3)Failures of conservative treatment by physiatrists for at least 6 weeks.

66. Methods The patients were evaluated by an independent observer before the initial injection (pre-injection) 2 weeks, 6 weeks, 3 months, 12 months Visual analog scale (VAS) Roland 5-point pain scale Standing tolerance, Walking tolerance Patient satisfaction scale

67. Methods

68. Results

69. Results

70. Results

71. Results

72. Conclusion The results from our study showed that, TFESI sig-nificantly reduced VAS and Roland 5-point pain scores for both short term and long term follow ups. However, standing tolerance and walking tolerance only signifi-cantly improved in the short term (for 2 weeks), but in the long term there was no significant difference. The pa-tient satisfaction scale for this procedure was highest at 2 weeks and declined with time. TFESI significantly reduced VAS and Roland 5- point pain scores for both short term and long term follow ups. Standing tolerance and walking tolerance only significantly improved in the short term (for 2 weeks), but in the long term there was no significant difference. The patient satisfaction scale for this procedure was highest at 2 weeks and declined with time.

73. Conclusion The results from our study showed that, TFESI sig-nificantly reduced VAS and Roland 5-point pain scores for both short term and long term follow ups. However, standing tolerance and walking tolerance only signifi-cantly improved in the short term (for 2 weeks), but in the long term there was no significant difference. The pa-tient satisfaction scale for this procedure was highest at 2 weeks and declined with time. All parameters indicated better outcome in one level of spinal stenosis patients than in two levels of spinal stenosis patients. These findings may be explained by the poor neural structures and physiology caused by double compression sites in neural elements.

74. Conclusion The results from our study showed that, TFESI sig-nificantly reduced VAS and Roland 5-point pain scores for both short term and long term follow ups. However, standing tolerance and walking tolerance only signifi-cantly improved in the short term (for 2 weeks), but in the long term there was no significant difference. The pa-tient satisfaction scale for this procedure was highest at 2 weeks and declined with time. The fluoroscopically guided lumbar TFESI is able to reduce VAS and Roland 5-point pain scale and improves standing tolerance and walking tolerance in the short term for DLS patients. For long term results, it reduces VAS but the improvement in standing tolerance and walking tolerance are limited. In addition, DLS patients with one level of spinal stenosis showed significantly better outcomes than DLS patients with two levels of spinal stenosis.

75. Is this good science? Interesting… Not sure why ODI or SF36 was not used… Small sample size

76. Is it important to PMR? Yes! If spondylolisthesis chose TFESI or facets? Another option besides surgery.

77. How will it change me and my practice with patients? Reinforces the TFESI for spondylolisthesis

78. Just Because We Have A Treatment… Doesn’t Mean Use it!!!!

79. David E. Fish, MD, MPH Physical Medicine and Rehabilitation Department of Orthopeadic Surgery