INTERNATIONAL SPINE INTERVENTION SOCIETY – 2013 21STANNUAL SCIENTIFIC MEETING RESEARCH ABSTRACTS

Outcome Results of Medial Branch NeurotomyUsing a Bipolar TechniqueRichard Derby, rderby@spinaldiagnostics.com,Irina Melnik, Jeong-Eun Lee, Richard FernandezA bipolar RF technique achieves a larger ablation areacompared to a single needle technique and may be analternative to single or multiple needle RF ablation tech-niques. However, the in vivo safety and efficacy of a bipolarRF technique has not been validated. We followed bothMBB and MBN complications and outcomes on a con-secutive series of 229 patients. 34% (78/229) selectingthose patients reporting 70% or greater relief followingone or two consecutive MBB who subsequently under-went MBN. The groups included 29 patients from singleMBB group and 15 patients from double MBB groupunderwent MBN. We prospectively collected audit dataand retrospectively collected data by phone interviews.We correlated MBN outcome with the degree of subjec-tive pain relief, duration of relief, patient’s satisfaction,activity improvement, no other doctor’s visits, and reduc-tion in medications use. 73% (32/44) of patients under-went MBNs using a bipolar technique. 83% of the patientsreported 50% or greater pain relief and 76% reported 6months or greater duration of relief. 78% of the patientsreduced or discontinued pain medications and 70.8% ofpatients reported 50% or greater ADL. 79% of patients nolonger visited a doctor because of their pain relief and 75%of patients scored “positive” for their satisfaction of treat-ment. Comparing above outcomes between bipolar andunipolar group, bipolar group showed statistically betteroutcomes than unipolar group for an average of pain reliefand ADL improvement. No complications occurred ineither group. Our MBN results indicate that the bipolartechnique is safe and may provide better outcome than asingle unipolar lesion and comparable outcomes to mul-tiple single lesions techniques.

Reliability and Safety of Contra-Lateral ObliqueView For Interlaminar Epidural Needle PlacementRichard Derby, rderby@spinaldiagnostics.com, Irina Melnik,Jongwoo Choi, Sang-Hoon Lee, Jeong-Eun LeeCord trauma is a risk of cervical and thoracic translami-nar epidural approach to the epidural space. Intermittentlateral fluoroscopic imaging to detect needle depth iscumbersome and often difficult to interpret. In compari-son, the contra-lateral oblique (CLO) fluoroscopy view isefficient and easy to interpret. However, the in vivo reli-

ability and safety of this technique has not been formallyinvestigated. The senior author collected fluoroscopyimages on 278 consecutive patients undergoing an inter-laminar epidural block at the T1-T2 level performedusing a 17-gauge tuohy needle. Before catheter place-ment, AP and CLO Fluoroscopic images were saved withthe needle at the ligamentum flavum and the needle justthrough the ligamentum flavum. We randomly selectedthe paired images of 40 cases that included the pairedCLO images (total 80 images) documenting the views ‘at’and ‘through’ the ligamentum flavum. Three interven-tionalists that did not perform cervical translaminar epi-dural injections were asked to review the images andscore the randomly selected and non-paired CLO fluo-roscopy images recording whether the 17-gauge needlewas in or out of the epidural space.

There was a 97.5%, 95%, and 93.8% agreementbetween each reviewing physician and the senior authorresulting in a correlation using the Kappa statistic valueof 0.950, 0.875, and 0.874 respectively (p < 0.001). Thethree reviewing physicians disagreed with senior author’scorrect answer in 2.5%, 5%, and 6.2% respectively,however, the disagreement occurred primarily because ofpoor image quality. Agreement between the three review-ing physicians was 93.8%, 96.3%, and 90%, with a Kappavalue of 0.875, 0.924, and 0.799 respectively (p < 0.001).One hundred percent technical success in the 278 caseseries without “wet taps”, provocation of pain duringentry, or any other complication.

Vascular Penetration Rate in Kambin’s TriangleSusan DiStasio, Boqing Chen, Todd Stitik, Lawrence Lai,Patrick Foye, New Jersey Medical SchoolObjective: Investigate rates of vascular penetrationusing an injection approach through Kambin’s triangle.Design: Retrospective case series. Setting: Outpatientmusculoskeletal office. Participants: Consecutive pati-ents with persistent lumbar radicular pain. Interven-tions: Lumbar transforaminal epidural steroid injections(LTESls) in an outpatient office. Digital subtractionangiography as part of real-time contrast-enhancedfluoroscopic guidance was used to aid identification ofvascular penetration. Main Outcome Measures: Inci-dents of vascular uptake. Level of Evidence: Level Ill.Results: 121 patients underwent a total of 202 LTESls.The first 64 patients received 101 injections duringwhich needle tips were situated at the posterior aspect

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PAIN MEDICINEVolume 14 • Number 8 • 2013

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of neuroforamina, as confirmed on lateral fluoroscopicviews. The total vascular penetration rate was 14%.Of the 89% of LTESls performed at the L4–5 andLS-S1 levels, the vascular penetration rate was 23%.When needle position in the posterior foramen wasfurther subdivided into upper, middle and lower thirdsas per lateral views, blood vessels were penetratedduring 13%, 0% and 20% respectively with needletips at the upper 1/3, middle 1/3 and lower 1/5 (needletip at upper edge of subjacent pedicle) of neuroforam-ina. To reduce vascular penetration chance, LTESls inthe subsequent 57 patients (101 injections) were per-formed with needle tips at the upper portion of thelower 1/3 of the neuroforamen. In this group (85% ofwhich were performed at the L4–5 and LS-S1 levels),vascular uptake dropped to 7%. Conclusions: DuringLTESls via Kambin’s triangle, needle tip in the upperportion of the lower 1/3 and posterior 1/2of theneuroforamen will encounter lowest vasculature uptakerates.

Lumbar Transforaminal Epidural Steroid Injections:Does Immediate Post-procedure Response PredictLonger-Term Response?C. El-Yahchouchi1, ce18@aub.edu.lb, J. Wald,2

J. Geske,2 N. Murthy,2 T. Kaufmann,2 K. Thielen,2

J. Morris,2 F. Diehn,2 K. Amrami,2 R. Carter,2

T. Maus2. 1American University of Beirut, 2Mayo ClinicEpidural anesthetics administered during transforaminalepidural steroid injections (TFESIs), may provideimmediate pain relief and temporary impairment ofmotor function. Relief of index pain suggests blockadeof the target nerve, but it is unknown if this predictslonger-term benefit. Objective: To assess whetherimmediate pain relief or weakness correlates withlonger-term improvement in pain and physical functionfollowing lumbar TFESIs in subjects with radicu-lar pain. Methods: Retrospective observational study of2024 lumbar TFESIs. Subjects were assessed with apain Numerical Rating Scale (NRS) and Roland-Morrisdisability questionnaire (R-M) prior to and followingTFESI, and at 2 weeks and 2 months follow-up. Tran-sient motor weakness was recorded. Successful painrelief was ≥50% reduction in NRS; functional successwas ≥40% reduction in R-M score. Logistic regressionmodels were used to determine if immediate post-procedure NRS score, percent improvement in NRSscore, or NRS or R-M response at 2 weeks predictedsuccessful outcomes at 2 months. C-indices assessmodel fit; higher values of the c-index (closer to 1) indi-cate better predictive power. Results: Immediate post-procedure NRS score, or percentage change in NRS,were poor predictors of 2 month outcomes (c-indices

[95% CI]:0.58 [0.55, 0.60]; 0.58 [0.56, 0.60] respec-tively). NRS or R-M response (c-indices [95% CI]:0.77 [0.75, 0.79], 0.80 [0.78, 0.82]) at 2 weeks morestrongly predicted 2-month response. Post-proceduremotor block did not predict 2-month outcomes. Con-clusion: Immediate post-TFESI pain relief does notpredict longer-term success in pain relief or func-tional recovery. Response in pain relief or functionalrecovery at 2 weeks strongly predicts outcomes at 2months.

Non-inferiority of Dexamethasone in LumbarTransforaminal Epidural Steroid InjectionsC. El-Yahchouchi,1 ce18@aub.edu.lb, J.Geske,2

N. Murthy,2 T. Kaufmann,2 K. Thielen,2 J. Morris,2

J. Wald,2 F. Diehn,2 K. Amrami,2 R. Carter,2 T. Maus2.1American University of Beirut, 2Mayo ClinicThe use of a non-particulate steroid in transforaminalepidural steroid injections (TFESIs) is thought tobe safer than particulate steroids. Efficacy of non-particulate steroids remains a concern. Available prag-matic studies on the relative efficacy of particulate andnon-particulate steroids are inconclusive. (1) Objec-tive: To assess whether the non-particulate steroiddexamethasone is less effective than particulate steroids(triamcinolone, betamethasone) in lumbar TFESIs insubjects with radicular pain with or without radiculopa-thy. Methods / Outcome Measures: Retrospectiveobservational study with non-inferiority analysis ofdexamethasone relative to particulate steroids on 3645lumbar TFESIs in 2634 subjects. Subjects were assessedwith a pain Numerical Rating Scale (NRS, 0–10) andRoland-Morris disability questionnaire (R-M) prior toTFESI and at 2 weeks and 2 months follow-up. Forcategorical outcomes, successful pain relief was definedas ≥50% reduction in NRS or pain 0/10; functionalsuccess was defined as ≥40% reduction in R-M score.Non-inferiority analysis was performed with δ = −10%as the limit of non-inferiority. Continuous outcomes(mean NRS, R-M scores) were analyzed for non-inferiority with difference bounds of 0.3 for NRS scoresand 1.0 for R-M scores. Results: At 2 months’ follow-up, dexamethasone was non-inferior to the particulatesteroids using categorical outcomes and superior to theparticulates using continuous outcomes for both painrelief and functional improvement. Conclusion: Thisstudy reveals no evidence that dexamethasone is lesseffective than particulate steroids in lumbar TFESIs.Reference: 1 Dreyfuss P, Baker R, Bogduk N. Com-parative effectiveness of cervical transforaminal injec-tions with particulate and non-particulate corticosteroidpreparations for cervical radicular pain. Pain Med 2006May-Jun; 7 (3): 237–42.

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A Randomized, Double-Blind, Multi-center,Prospective Study Comparing the Efficacy ofParticulate vs Non-Particulate Corticosteroids forLumbar Radiculitis due to an Acute HerniatedNucleus PulposusDavid J. Kennedy, Christopher Plastaras, Ellen Casey,Christopher J. Visco, James D. Sigler, Matthew Smuck,Bryan Conrad, Paul DreyfussObjective: To compare the efficacy of particulate (triam-cinolone 60 mg) versus non-particulate (dexamethasone15 mg) corticosteroids for acute uni-lateral, uni-levelradicular pain due to a herniated nucleus pulposus.Methods: Multi-center, randomized, double blind con-trolled trial. 78 subjects with <6 months of uni-lateral,uni-level lancinating radicular pain due to herniatednucleus pulposus demonstrated on MRI that failedconservative therapy and required interventional care.Subjects were randomized to receive either 60 mg triam-cinolone or 15 mg dexamethasone via lumbar transfo-raminal epidural injection by an independent physician.Subjects were followed at 2 weeks, 3 months, and6 months. Main Outcome Measures: The primaryoutcome measures were the need for surgery and numberof injections received. Secondary outcome measures werecategorical percentage of subjects having 50% painreduction and Oswestry Disability Index at 2 weeks, 3months and 6 months. Results: There was a staticallysignificant difference in the total number of injectionsreceived between the groups, with a greater percentage ofthose receiving dexamethasone requiring 3 injectionswhen compared to those receiving triamcinolone. Therewere no significant differences in surgical rates with13.7% of the dexamethasone group and 17.9% of thetriamcinolone group requiring surgery. Pain relief alsodid not vary between groups with the dexamethasonegroup having 82.8% of subjects receive 50% pain reduc-tion at 6 months, and the triamcinolone group having93.8% with 50% reduction in pain at 6 months. Conclu-sions: There were no statistically significant differencesin pain relief or surgical rates between the steroids.However the dexamethasone group statically requiredmore injections to achieve this result than the triamcino-lone group.

A Randomized, Double-Blind, Placebo-Controlled,Prospective Study of Intra-articular LumbarZygapophysial Joint Corticosteroid Injection(s) asTreatment of Chronic Low Back Pain in aSelected PopulationDavid J. Kennedy, Alison Stout, Bryan Conrad,Matthew SmuckBackground data: Lumbar zygapophysial joint (z-joint)pain is common and the intra-articular (IA) injection ofcorticosteroids are a frequently utilized treatment for this

condition. To date no studies have been done on theefficacy of intra-articular steroids in those with dual com-parative medial branch block confirmed z-joint pain.Objective: To determine if intra-articular injection ofcorticosteroid are effective in reducing the need forradiofrequency ablation in those with dual medial branchblock confirmed z-joint pain. Methods: Randomized,double blind, placebo-controlled study. 28 subjects wereenrolled. Subjects with dual comparative medial branchblock confirmed z-joint with >80% relief with dualblocks, pain relief from a patient specific physical exammaneuver, and pain relief concordant with the two dif-ferent anesthetics injected underwent either intra-articular corticosteroid (triamcinolone 20 mg) or salinevia fluoroscopic injection. Subjects and treating physicianwere blinded to the treatment. Results: The primaryoutcome measure was the categorical need for a radiof-requency (RF) ablation. There was no statistical signifi-cant difference in the need for an RF between the groups(70% vs 76.1%). The average time to RF was also notdifferent at 6.1 weeks vs 6.5 weeks. Secondary outcomemeasures included Pain, Oswestry Disability Index,SF-36, and time to RF. Given the high numbers of thosegoing onto RF, the secondary outcome measures includ-ing were not felt to be valid since there were so fewsubjects that did not have an RF. Conclusions: Intra-articular corticosteroids were not effective in reducingthe need for a radiofrequency ablation of the medialbranches in those with dual medial branch block con-firmed z-joint pain.

Impact of Tc-99 m MDP SPECT/CT onPercutaneous Facet Joint Intervention inClinical PracticeVance Lehman, Lehman.vance@mayo.edu, Robert Murphy,Felix Diehn, Naveen Murthy, Jonathan Morris,Timothy Maus. Department of Radiology. Mayo Clinic,Rochester MNSummary of Background Data: Prior studies suggestbone scan activity predicts facet joint pain. Objec-tives: Characterize the pattern of percutaneous facet jointintervention in clinical practice when SPECT/CT data isavailable. Methods: Patients undergoing percutaneouslumbar or cervical facet joint intervention within 100 daysof a prior Tc-99 m MDP SPECT/CT at our institutionbetween 1/1/2008 and 4/12/2012 were identified. Loca-tion of facet joint activity was compared to those sites thatwere targeted for percutaneous intervention (steroidinjection or medial branch block). Apparent rationale fordiscrepancy between facet joint activity and treatment wasevaluated. Results: 51 patients (30 females, average age 57years) were identified with a total of 128 facet jointstherapeutically targeted. 63/128 (49%) targeted facet

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joints demonstrated activity while 65/128 (51%) targetedfacet joints did not. 63/92 (68%) active facet joints weretargeted while 29/92 (32%) active facet joints were nottargeted. In 17/51 (33%) patients therapeutic targetingwas perfectly concordant with activity, while 34/51 (67%)patients had at least one discrepant joint. The mostcommon documented rationale for discrepancy was poorcorrelation to clinical exam in 9/34 (26%) patients; avariety of other reasons were less common. Conclu-sion: Facet joint activity on Tc-99 m MDP SPECT/CThas an inconsistent impact on targeted facet joint inter-vention in current clinical practice. Documented reasonsfor these discrepancies are variable. Clinical practice is notclosely aligned with the existing literature. Further out-comes studies assessing the role of Tc-99 m MDPSPECT/CT in the management of facet joint painare needed.

Lumbar Intradiscal Platelet Rich Plasma Injections:A Prospective, Double-Blind, RandomizedControlled TrialAlon Terry, Elizabeth E. LaSalle, Bella Shah,Joseph T. Nguyen, Jennifer L. Solomon, Gregory E. LutzBackground: The trend in spine care is a search for safebiologic treatments. Recent animal studies demon-strated that platelet rich plasma has both a protectiveand reparative effect on a damaged intervertebral disc.Objective: To determine if a single intra-discal injectionof PRP at the time of discography has potential thera-peutic value. Methods: Patients with a history ofchronic lumbar discogenic pain underwent provocativediscography. Patients with concordant pain and annulardisruption were randomized (2:1) to receive eitherplatelet-rich plasma or additional contrast agent.Outcome measures included the NRS, modified NASSoutcome questionnaire, FRI, and SF-36 for physicalfunctioning and pain. Results: A total of 31 patientswere enrolled in the study with data collected on 30patients (follow-up rate 97%).19 were in the treatmentgroup and 11 were in the control group. There were 17males and 13 females with an average age of 43 (22 to61 years old) and duration of symptoms of almost 4years (6 months to 20 years). There was statistically sig-nificant improvement in outcome scores between thegroups at 8 weeks in SF-36, FRI, and NRS. Theseimprovements in pain and function were seen in themajority of patients receiving PRP for up to at least oneyear (2 months to 46 months). The treatment groupalso reported a statistically higher satisfaction rate(NASS) when compared to the controls (61% vs. 11%respectively). There were no adverse reactions reported.Conclusion: This study demonstrates statistically sig-nificant and clinically relevant improvements in pain

and function in a subset of patients who received intra-discal PRP. Further study is warranted.

A Systematic Review of Head-to-head EvidenceComparing Transforaminal to Interlaminar EpiduralSteroid Injection for the Treatment of LumbosacralRadicular PainZack McCormick MD1, zmccormi@gmail.com,George Chang Chien DO1, Samuel K Chu MD1,Kennith Candido MD2. 1The Rehabilitation Instituteof Chicago, Chicago, IL, 2Advocate Illinois MasonicMedical Center, Chicago, ILBackground: Controversy exists regarding superiority ofTFESI or ILESI for the treatment of lumbosacral radicu-lar pain (LSRP). We systematically reviewed studiesdirectly comparing the efficacy of these two approaches.Methods: Studies comparing TFESI to ILESI for LSRP,prior to January 2013, were identified in PubMed®. Ifstudies met the Cochrane Review (CR) criteria for RCTsand the AHCQ criteria for observational studies, theywere included. Evidence was graded according to theUSPSTF classification. Clinical significance was definedby pain and functional score improvements greater than20% and 10%, respectively, consistent with CR guide-lines. 6 months was defined as “long-term.” Results: 10studies met criteria. For the treatment of LSRP due todisc herniation (DH), there is level 1 evidence both insupport and opposition of short or long-term clinicallysignificant improvement in pain scores with TFESI com-pared to ILESI. There is level 1 evidence both in supportand opposition of improvement in disability with TFESIcompared to ILESI in both the short and long-term. Forthe treatment of LSRP due to spinal stenosis (SS), oneretrospective study found no difference in short-termpain or functional outcomes between TFESI and ILESI.Conclusions: This systematic review suggests thatTFESI is moderately superior to ILESI for short andlong-term treatment of pain and disability, thoughnotably; the literature is not unanimous in this conclu-sion. For the treatment of LSRP due to SS, there is nohead-to-head evidence for superiority of either approach.

The Hazard of Nerve Injury During LateralAtlanto-Axial Joint InjectionsJohn MacVicar,* john.macvicar@southernrehab.co.nz,Anne MacVicar,* Nikolai Bogduk**. * SouthernRehabilitation Institute, Christchurch, New Zealand,** Department of Clinical Research, Royal Newcastle Centre,Newcastle, AustraliaObjectives: In response to concerns about the techniquedescribed in the first edition of the ISIS practice guide-lines1, the present study was undertaken to determinethe risk of encountering the C2 spinal nerve or itsbranches during lateral atlanto-axial joint injections.

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Design: Retrospective practice audit. Methods: Recordsand images of all patients who underwent lateral atlanto-axial joint injections between June 2004 and March 2013were reviewed. Results: 101 injections were performedon 53 patients. For 60 cases, images showed final, intra-articular needle placement but not initial placement onbone. In no case was a nerve encountered. In 41 cases,images showed initial placement on the lateral mass ofthe atlas in 34, and on the superior articular process of theaxis in seven. A nerve was encountered in five cases. Inone case the C2 dorsal root ganglion was encounteredbefore the needle reached bone. In the remaining fourcases, a nerve - presumably the C2 ventral ramus - wasencountered after bone contact, when the needle wasmoved toward the joint space. Conclusion: The choiceof initial bone contact appears immaterial to the risk ofencountering a nerve. A nerve is most likely to beencountered when attempting to enter the joint cavity,but the likelihood is low: 4.0% ± 3.8%. The techniquedescribed in the ISIS Practice Guidelines is fundamen-tally safe, but care must be taken not to injure the nerveduring final placement of the needle. References: 1.Lateral Atlanto-Axial Joint Blocks. In: Bogduk N (ed).Practice Guidelines for Spinal Diagnostic and TreatmentProcedures. International Spine Intervention Society,San Francisco, 2004.

Efficacy of Multiple Transforaminal EpiduralSteroid Injections (TFESI)Naveen Murthy, murthy.naveen@mayo.edu,Jennifer Geske, John Wald, Felix Diehn, Kent Thielen,Timothy Kaufmann, Jonathan Morris, Vance Lehman,Kimberly Amrami, Rickey Carter, Timothy Maus. MayoClinic.Multiple TFESIs are often performed for radicular painhoping for cumulative benefit; clinicians have anecdotallynoted that the effectiveness of TFESIs may diminish withrepetition. There is no objective data to assess these com-peting positions. Objective: To determine if multipleTFESIs lead to cumulative, or diminishing, effectivenessin pain relief for treating single level radicular pain.Method: A retrospective review was performed of 933patients who received two+ TFESIs (2087 total injec-tions) separated by at least two weeks and performedwithin one year. For each injection, a numeric rating scale(NRS, 0–10) was obtained prior, and at 2 weeks and 2months following. Improvement was defined as 50% orgreater reduction in NRS compared to pre-injection. Athree-level Hierarchical Linear Modeling (HLM) wasused to test for a change in NRS, and a two-level HLMwas used to test for change in probability of 50% orgreater reduction in NRS. Results: The NRS at 2months was found to increase with subsequent injections

(β = 0.268, p-value = 0.016), after adjusting for chronicityof pain and baseline pain at the first injection. There wereno statistically significant differences in NRS prior toinjection or at 2 weeks following injection, by number ofinjection. The probability of at least 50% reduction inNRS at 2 months significantly decreases with subsequentinjections (OR = 0.826, p-value = 0.038). Patients treatedwith multiple TFESIs didn’t experience cumulativebenefit with each subsequent injection at 2 monthsfollow-up, independent of chronicity and baseline pain.NRS at 2 months follow-up increased minimally (0.3NRS), and probability of at least 50% improvementdecreased with additional TFESIs.

A Randomized, Placebo Controlled Study toAssess the Efficacy of Lateral Branch Denervationfor Chronic Sacroiliac Joint Pain; 12 MonthFollow UpNilesh Patel, M.D., npatel@apmhealth.comSummary of background data: Sacroiliac joint painrepresents a significant and under-addressed medicalcondition.

A growing body of literature supports the use of cooledradiofrequency denervation as a treatment option offer-ing long-term relief from pain.1,2,3. Objective: Tocompare the efficacy of Cooled radiofrequency lateralbranch neurotomy to a sham intervention for sacroiliacjoint pain. Methods: Randomized, sham-controlledstudy of 51 injection confirmed sacroiliac joint painpatients. Lesions performed with SInergy System (Kim-berly Clark) at S1-S3 lateral branches and L5 DorsalRamus. Subjects and assessors blinded until 3-months.Sham subjects followed for 3 months, then crossed overto treatment for 6 additional months. Treated subjectswere followed 12-months. Outcomes evaluated includedNRS, ODI, SF36 BP/PF and AQoL. Results: Treatmentwas well tolerated with no serious complications. In theTreatment group, 12 month outcomes persisted com-pared to baseline with mean Pain NRS maintaining a2.22 drop, ODI decreased 12.1, SF-36 BP increased13.73, AQoL 0.68 and SF-36 PF increased 13.89.Twelve-month treatment group values show consistencywith 6-month crossover follow up results. Conclu-sion: Treatment results highlight persistent improve-ments in pain/disability/physical function/quality of lifethrough 12 month follow up compared to baseline. Dura-bility of relief is consistent with previous studies, currentresults highlight benefits extending beyond 12-months.References: 1. Cohen SP. Randomized placebo-controlled study evaluating lateral branch radiofrequencydenervation for sacroiliac joint pain. Anesthesiology2008;109:279–88. 2. Kapural L. Cooled Radiofrequency(RF) System for the Treatment of Chronic Pain from

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Sacroiliitis: Pain Practice 2008;8:348–54. 3. Steltzer W.Use of Cooled Radiofrequency Lateral Branch Neu-rotomy for the treatment of Sacroiliac Joint MediatedLow Back Pain: A Large Case Series. Pain Medicine2013; 14:29–35.

Autogenous Point of Care Bone MarrowConcentrate (BMC) for the Treatment of CervicalDegenerative Disc DiseaseKenneth A. Pettine, MD, Matthew Pouliot, DO. The StemCell Institute, 4795 Larimer Parkway, Johnstown,CO 80534Background: The use of autogenous BMC may provide anon-surgical option for the treatment of cervical degen-erative disc disease. Purpose: Evaluate the safety andefficacy of autogenous BMC for the non-surgicaltreatment of moderate to severe cervical degenerativedisc disease. Study Design: Prospective non-randomizedstudy representing class II data. Patient Sample: Thirty-two patients (16 females, 16 males) were injected withautogenous BMC into 66 cervical discs. The averageage was 53 with an average BMI of 26.2. OutcomeMeasures: Pre-procedure neck disability index (NDI),visual analog scale (VAS), physical examination, andMRI scanning. Patients were followed prospectively atsix weeks, three months, and six months with repeatMRI at six months. Methods: The procedure takes 30minutes and consists of IV sedation utilizing Versed andIV Fentanyl. Percutaneous aspiration of the posterioriliac wing is performed to obtain 60 ml of bone marrowaspirate followed by concentration utilizing the SpineSmith ART-21 system. 0.5 ml of BMC was injected intoeach symptomatic cervical nucleus with a standardanterolateral approach to the disc with a 22-gaugespinal needle. Results: Average pre-procedure NDI was43.6%, which improved to 23.8% at six months (p-value< 0.001). Pre-procedure VAS was 54, which improvedto 25 at six months (p-value < 0.0001). At up to one-year follow-up in this group, no patient has undergonesurgery. There was one discitis treated with antibiotics.Conclusion: Preliminary results indicate safety and sta-tistical efficacy. Results indicate autogenous BMC hasclinical efficacy for the non-operative treatment ofdegenerative disc disease in the cervical spine. Patientswill be followed for a minimum of two years.

Autogenous Point Of Care Bone MarrowConcentrat (BMC) For The Treatment Of LumbarDegenerative Disc Disease In Self-Pay PatientsKenneth A. Pettine, MD, Matthew Pouliot, DO. The StemCell Institute, 4795 Larimer Parkway, Johnstown, CO80534Background: The use of autogenous BMC may providea non-surgical option for severe symptomatic lumbar

degenerative disc disease. Purpose: Evaluate the safetyand efficacy of autogenous BMC. Study Design: Pro-spective non-randomized evaluation. Patient Sample:Sixty-one patients had a total of 161 lumbar discsinjected with autogenous BMC. Average age was 50 yearsand average BMI was 26.9. Outcome Measures: Pre-procedure oswestry disability index (ODI), visual analogscale (VAS), physical examination, and MRI scanning.Patients were followed prospectively at six weeks, threemonths, and six months with repeat MRI at six months.Methods: The procedure takes 30 minutes and consists ofIV sedation utilizing Versed and IV Fentanyl with thepatient in the prone position. Percutaneous aspiration ofthe posterior iliac wing is performed to obtain 60 ml ofbone marrow aspirate followed by concentration utilizingthe Spine Smith ART-21 system. 2–3 ml of BMCwas injected into each symptomatic lumbar nucleuswith standard two-needle discography technique.Results: Average pre-procedure ODI was 44.7%, whichimproved to 25.2% at six months, and 27.2% at 12 months(p-value < 0.0001). The VAS averaged 61 pre-procedure,which improved to 34 at six months, and 38 at 12 months(p-value < 0.0001). Thus far, only two patients have under-gone a surgical procedure following the injection. Therehave been no complications. Conclusion: Preliminaryresults indicate safety and statistical efficacy. Two patientshave undergone a surgical procedure following the injec-tion. Six-month follow-up results indicate autogenousBMC has clinical efficacy for the non-operative treatmentof degenerative disc disease in the lumbar spine. Patientswill continue to be followed for two years.

Positional Dorsal CSF Thickness Change as theFoundation for Adaptive Spinal Cord StimulationWenchun Qu,1,2 Qu.Wenchun@mayo.edu, Yuexiang Wang,1

Michael Hooten,1 Kent Thielen,3 Timothy Maus3.1Department of Anesthesiology Pain Medicine Division,2Department of Physical Medicine and Rehabilitation,3Department of Radiology, Mayo Clinic, Rochester, MNBackground: Spinal cord stimulation (SCS) has beenshown to provide significant pain relief by generatingparesthesias over the region of pain. The stimulationintensity has clinically been observed to change withbody position, hypothesized to be due to the changes inthe dorsal CSF thickness (dCSF), resulting in overstimu-lation or understimulation in supine and upright posi-tions respectively. No study has examined the dCSFthickness throughout the entire spinal cord. Objec-tives: This study uses CT myelography to investigatethe position of the spinal cord from C2-L2 in prone andsupine positions. Methods: Ten patients were studiedwith dynamic CT myelography in prone and supinepositions. The dorsal CSF distance between spinal cord

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and dura (dCSF) was measured in both prone and supinepositions. To adjust for the angulation during scanning, adCSF index, a percentage computed by [(dCSF/APdiameter of spinal canal)*100], was used for comparisonbetween positions. Results: dCSF are greatest at mid-thoracic levels and smallest at upper cervical levels inboth prone and supine positions. Positional changes ofdCSF index from supine to prone positions variesbetween −4.9% to 8%. Non-parametric studies withexact Wilcoxon test shows a trend toward widening ofdCSF at thoracic levels and narrowing at cervical levels,with no statistical significance at the α < 0.05 level. Con-clusion: This study shows that there is limited move-ment of the spinal cord in the sagittal plane of the spinalcanal. Whether the change would be adequate to affectstimulation effect remains to be further investigated.

Comparison of Transforaminal Epidural Injectionsof Methylprednisolone and Dexamethasone in theTreatment of Lower Back Radicular PainMatthew Schaeffer MD, Drschaeff2004@yahoo.com,Jeffrey Citara DO, Jimmy Miller. Premier Orthopaedic &Sports Medicine Associates, West Chester, PAObjective: To determine if epidural injections of dexa-methasone and methylprednisolone are equally effective.Design. Sixty-two patients with lumbar radicular painwere randomized to receive equivalent doses of dexa-methasone or methylprednisolone via transforaminalinjection. Preoperative testing included Visual AnalogScale and Oswestry Back Disability Index. Postoperativetesting included Visual Analog Scale at one and twoweeks and three months. Oswestry Disability Index,Patient Satisfaction Survey and Pain Medication Reduc-tion surveys were administered at two weeks and threemonths. Results. Both groups demonstrated significantreductions on the visual analog scale at one and twoweek’s post-op. The methylprednisolone group main-tained significant reduction on the visual analog scale atthree months. Both groups demonstrated a decreasedscore on the Oswestry Disability Index at two weekspost-op and neither group maintained the significantreduction at three months. There was no statistical dif-ference in the patient satisfaction survey after two weeks(86% Methylprednisolone, 77% dexamethasone) orthree months (81%, 77%). There was statistical differ-ence in the Pain Medication Reduction survey after twoweeks (79% methylprednisolone, 57% dexamethasone)and three months (77%, 54%). Conclusion: Methyl-prednisolone and Dexamethasone are near equally effec-tive in the short term reduction of lumbar radicular pain.Methylprednisolone may be more effective than dexa-methasone in sustained reduction of pain and in reducingthe use of pain medications. References: White AH,Derby R, Wynne G. Epidural injections for diagnosis and

treatment of low-back pain. Spine 1980;5:78–86. ChanHong Park, Sang Ho Lee, Bong Kim. Comparison of theEffectiveness of Lumbar Transforaminal Epidural Injec-tion with Particulate and Nonparticulate Corticosteroidsin Lumbar Radiating Pain. Pain Medicine 2010;11:1654–1658.

Epidural Lipomatosis as a Cause for HighImpedance Values during a Spinal Cord StimulatorTrial: A Case ReportCarolyn F. Schulz MD.,1 Daniel A. Fung MD.,2

Timothy T. Davis MD.2. 1UCLA/Greater Los AngelesVA Health Care System, Los Angeles, CA.2The Center for Spine and Joint Restoration, Santa Monica,CAIntroduction: Spinal cord stimulators (SCS) have beenused to treat a variety of pain conditions. SCS involveslead placement and stimulation in the lower thoraciclevels usually without drastic changes in impedancevalues. Spinal epidural lipomatosis (SEL) is a rare patho-logical overgrowth of adipose tissue in the extraduralspace that has been linked to excess exogenous cortisoluse or endogenous cortisol production. To date, thereis limited published literature on how SEL mayaffect impedance values during a neuromodulation trial.Methods: A 43 year old female patient with history ofchronic low back pain and prior lumbar fusion who pre-sented with persistent bilateral lower extremity dysesthe-sic pain radiating from her waist to her feet and wasdeemed an appropriate candidate for a SCS trial. Duringlead placement, significantly higher impedance valueswere noted in an area dorsal to the T8 vertebral bodycompared to adjacent levels. Leads were then successfullyplaced at the level above, but the intraoperative andensuing outpatient trial failed to relieve her neuropathicpain between the waist and popliteal fossa bilaterally.Results: The trial was unsuccessful and the leads wereremoved without complication. A subsequent MRI of thethoracic spine revealed T8 dorsal epidural lipomatosisthat directly correlated to the high impedance levelsduring the spinal cord stimulator trial. Conclu-sion: Spinal epidural lipomatosis can greatly increaseepidural impedance values and should be consideredwhen physicians encounter abnormally high valuesduring a SCS trial. SEL may also contribute to SCS trialfailure rates.

Salvaging Failed Conventional Spinal CordStimulation Implants With Nevro High FrequencySpinal Cord SystemPaul Verrills MD, Bruce Mitchell MD, David Vivian MD,Gillian Nowesenitz, Adele Barnard PhD and Anton KolosovPhD. Metro Pain Clinic, Melbourne, AustraliaSummary of Background Data: Conventional spinalcord stimulation (CSCS) is a successful treatment option

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for patients with chronic back pain. However, it producesa number of unwanted sensations (paraesthesia) and maybecome ineffective over time. Nevro SCS operates at ahigher frequency, and as such may have a differentmechanism of action than conventional systems. Objec-tives: 12 months prospective study is set out to evaluatethe efficacy of Nevro SCS in chronic back pain patientsfollowing failed CSCS implants. Methods: 33 patientswith chronic back pain implanted with CSCS systems,which failed to provide pain relief, were recruited for thestudy. Patients’ levels of pain and disability, activities ofdaily living, analgesic use and psychometrics was assessedprior to Nevro device trial (pre), 7 days following trial(post) and at 3, 6 and 12 months following Nevro implant(follow-up). Adverse events were monitored. Study was

IRB approved. Results: 21 patients with failed CSCSimplants had a successful trial of Nevro device and wenton to have a permanent Nevro SCS implant. All patientshad significant reduction of mean back pain (pre: 6.9 ±1.9; post: 2.6 ± 1.6; follow-up: 3.8 ± 2.3 and 3.8 ± 1.6 at 3and 6 months respectively; p ≤ 0.0001). Positive trendstowards improved daily activities, psychological state anddecreased medication use were observed post-implant.Discussion/Conclusion: Nevro high frequency SCStherapy provides effective pain relief and improved func-tional state in a cohort of patients with failed CSCSsystems. The results of this study point the way to a newand successful therapeutic option for cases where efficacyof the CSCS system is significantly diminished orcompromised.

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