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Day: March 3, 2016

Evaluation and Interventional Management of Pain After Vertebral Augmentation Procedures

By wp_zaman

INTRODUCTION: A small subset of patients who underwent successful vertebral compression fracture (VCF) augmentation procedures may develop subsequent pain requiring spinal injections. In a retrospective analysis, we determined whether the pain was related to the original fracture site or to another area within the lumbar or thoracic spine. The pain occurred either at the same/adjacent level and/or non-adjacent level as the VCF. Interventional treatments primarily targeted the facet joints, specifically in the form of facet joint blocks and/or radiofrequency ablation to the medial branches. The pattern of facet injections relative to the original fracture level was studied. Additionally, the elapsed time between the vertebral augmentation and the subsequent interventional blocks was also evaluated. METHODS: A total of 56 patients sustained VCFs. 12 of these patients underwent interventional procedures after vertebral augmentation procedures. The level(s) of same/adjacent level and non-adjacent level pain were determined via physical examination and/or imaging studies. These levels were subsequently treated with interventional procedures primarily focused on the facet joints. The time period of the injections varied from two weeks status post-vertebral augmentation to as late as 304 weeks (5.8 years) status post-vertebral augmentation. RESULTS: We performed 25 vertebral augmentation procedures on these 12 patients. 15 lumbar, eight lower thoracic, and two mid-thoracic VCFs were augmented. 9/14 cases of blocks included those performed at non-adjacent levels, whereas 5/14 cases of blocks were performed only at the same and/or adjacent levels as the VCF. For the events in which thoracic VCFs were augmented, 6/7 (or 86%) had developed non-adjacent level pain in areas of the lumbar spine. The time from vertebral augmentation procedure to subsequent pain procedure ranged from two weeks to five plus years. The average time elapsed was 83 weeks. Only one case required blocks performed within the first six weeks after vertebral augmentation. In this case, the blocks included those at non-adjacent levels. A total of 4/12 cases (33%) had a block within 12 weeks of the original vertebral augmentation procedure. Lumbar spine imaging showed that at least 9/12 patients had pre-existing significant lumbar pathology at the time of fracture treatment. This may have contributed to the later development of pain. CONCLUSION: Pain after a successful vertebral augmentation is typically non-acute (i.e., beyond six weeks). Mechanisms other than the primary VCF are usually responsible for non-adjacent level pain, which are present a majority of the time on reviewing the patients’ diagnostic studies. These mechanisms usually take many weeks to develop and subsequently elicit pain that requires additional interventional pain procedures. In our study, the pain is usually related to the pre-existing degenerative spondylosis and stenosis rather than the fracture site. This study shows that the facet joints in closely related lumbar degenerative changes are the cause of pain in this patient group. These procedures should be explored with pain after vertebral augmentation, especially in those patients with known or suspected spinal degeneration and/or poor biomechanics

Symptomatic Magnetic Resonance Imaging-Confirmed Lumbar Disk Herniation Patients: A Comparative Effectiveness Prospective Observational Study of 2 Age- and Sex-Matched Cohorts Treated With Either High-Velocity, Low-Amplitude Spinal Manipulative Therapy or Imaging-Guided Lumbar Nerve Root Injections.

By wp_zaman

Symptomatic Magnetic Resonance Imaging-Confirmed Lumbar Disk Herniation Patients: A Comparative Effectiveness Prospective Observational Study of 2 Age- and Sex-Matched Cohorts Treated With Either High-Velocity, Low-Amplitude Spinal Manipulative Therapy or Imaging-Guided Lumbar Nerve Root Injections.

J Manipulative Physiol Ther. 2013 May 22;

Authors: Peterson CK, Leemann S, Lechmann M, Pfirrmann CW, Hodler J, Humphreys BK

Abstract
OBJECTIVES: The purpose of this study was to compare self-reported pain and “improvement” of patients with symptomatic, magnetic resonance imaging-confirmed, lumbar disk herniations treated with either high-velocity, low-amplitude spinal manipulative therapy (SMT) or nerve root injections (NRI). METHODS: This prospective cohort comparative effectiveness study included 102 age- and sex-matched patients treated with either NRI or SMT. Numerical rating scale (NRS) pain data were collected before treatment. One month after treatment, current NRS pain levels and overall improvement assessed using the Patient Global Impression of Change scale were recorded. The proportion of patients, “improved” or “worse,” was calculated for each treatment. Comparison of pretreatment and 1-month NRS scores used the paired t test. Numerical rating scale and NRS change scores for the 2 groups were compared using the unpaired t test. The groups were also compared for “improvement” using the χ(2) test. Odds ratios with 95% confidence intervals were calculated. Average direct procedure costs for each treatment were calculated. RESULTS: No significant differences for self-reported pain or improvement were found between the 2 groups. “Improvement” was reported in 76.5% of SMT patients and in 62.7% of the NRI group. Both groups reported significantly reduced NRS scores at 1 month (P = .0001). Average cost for treatment with SMT was Swiss Francs 533.77 (US $558.75) and Swiss Francs 697 (US $729.61) for NRI. CONCLUSIONS: Most SMT and NRI patients with radicular low back pain and magnetic resonance imaging-confirmed disk herniation matching symptomatic presentation reported significant and clinically relevant reduction in self-reported pain level and increased global perception of improvement. There were no significant differences in outcomes between NRI and SMT. When considering direct procedure costs, the average cost of SMT was slightly less expensive.

PMID: 23706678 [PubMed – as supplied by publisher]

Antigen-induced arthritis in rats is associated with increased growth-associated protein 43-positive intraepidermal nerve fibres remote from the joint.

By Kamruz Zaman
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Antigen-induced arthritis in rats is associated with increased growth-associated protein 43-positive intraepidermal nerve fibres remote from the joint.

Arthritis Res Ther. 2015;17:299

Authors: Jochmann E, Boettger MK, Anand P, Schaible HG

Abstract
INTRODUCTION: Pain in arthritis may be experienced in regions outside the affected joint, and hyperalgesia may even be widespread. The spread of pain is usually attributed to mechanisms in the central nervous system. We investigated whether rats with antigen-induced arthritis (AIA) exhibit peripheral changes in skin innervation remote from the inflamed joint.
METHODS: After immunization, unilateral AIA in the knee joint was induced in rats. Intraepidermal nerve fibre density was determined by immunohistochemical staining for protein gene product 9.5 (PGP 9.5) and for nerve fibres expressing calcitonin gene-related peptide (CGRP), substance P (SP), transient receptor potential vanilloid 1 (TRPV1; the heat and capsaicin receptor), β-tubulin, and growth-associated protein 43 (GAP-43; a marker of regenerating nerve fibres) in paw pad skin and back skin. Cluster of differentiation 11b (CD11b)-positive macrophages and CD3-positive T cells were quantified in skin, and macrophages were quantified in the lumbar dorsal root ganglia. In addition, pain-related behaviour was assessed.
RESULTS: Intraepidermal nerve fibre density (PGP 9.5) and the numbers of fibres expressing CGRP, SP, TRPV1, or β-tubulin did not show a significant change in the acute (3 days) or chronic phase (21 days) of AIA compared with control rats that were only immunized. However, paw skin and back skin revealed a significantly higher number of nerve fibres expressing GAP-43 at both the acute and chronic stages of AIA. The skin of arthritic rats in these regions did not contain a greater density of CD11b and CD3 immune cells than the skin of control rats. Enhanced expression of GAP-43 in nerve fibres of the skin was not related to hyperalgesia in the joint, but it accompanied persistent secondary cutaneous hyperalgesia in the skin remote from the inflamed joint.
CONCLUSIONS: Although the innervation of the skin remote from the joint did not show significant abnormalities of the other nerve fibre markers, the rapid and persistent increase of GAP-43 expression is conspicuous. The data suggest that immune-mediated arthritis is associated with changes in skin innervation remote from the inflamed joint, although the skin is not inflamed, which may contribute to symptoms in nonarticular tissue remote from the affected joint.

PMID: 26503622 [PubMed – indexed for MEDLINE]

Lumbar spinal stenosis treatment with aperius perclid interspinous system.

By wp_zaman

Lumbar spinal stenosis treatment with aperius perclid interspinous system. Eur Spine J. 2012 Mar 20; Authors: Surace MF, Fagetti A, Fozzato S, Cherubino P Abstract PURPOSE: The purpose of this study is to report clinical outcome and imaging changes of percutaneous Aperius stand-alone implant in patients with degenerative lumbar spinal stenosis and neurogenic intermittent claudication,…