Background Context. Patients who do not improve after lumbar surgery may be given the nonspecific label of "failed back surgery syndrome (FBSS)." Since 1981, there has not been a quantitative assessment of the etiologies of FBSS despite major improvements in surgical techniques and diagnostic testing. Purpose. To define the causes of FBSS seen in a referral-based spine center. Study Design and Methods. Retrospective review of 181 consecutive charts of patients seen at a single spine center because of continued pain after lumbar surgery performed elsewhere. Evaluation was individualized based on history and physical examination and included x-rays, CT scans, MRI, selective nerve root injections, discography, and psychiatric evaluation. Patient Sample. There were 101 men and 80 women; mean age was 47 years. There were 118 patients with one prior surgery, 52 with two, 6 with three, and 5 with four. Mean interval from the last prior surgery to the first clinic visit was 33 months. Results. A predominant diagnosis could be established in 170 of 181 (94%) patients, and included foraminal stenosis (29%), painful disc(s)(17%), pseudarthrosis (14%), neuropathic pain (9%), instability (5%), and psychological problems (3%). Conclusion. We were able to establish a predominant diagnosis in 94% of our patients. Foraminal stenosis remains the leading cause of FBSS, but painful discs are also common. Recurrent disc herniation is seen less often than in the past, and there is increased recognition of neuropathic pain. Knowledge of the potential causes of FBSS leads to a more efficient and cost-effective evaluation of these patients.

Background. Transforaminal injection of steroids is used to treat lumbar radicular pain. Not known is whether the route of injection or the agent injected is significant. Study Design. A prospective, randomized study compared the outcomes of transforaminal injection of steroid and local anesthetic, local anesthetic alone, or normal saline, and intramuscular injection of steroid or normal saline. Patients and outcome evaluators were blinded as to agent administered. Methods. The primary outcome measure was the proportion of patients who achieved complete relief of pain, or at least 50% relief, at 1 month after treatment. Secondary outcome measures were function, disability, patient-specified functional outcomes, use of other health care, and duration of relief beyond 1 month. Results. A significantly greater proportion of patients treated with transforaminal injection of steroid (54%) achieved relief of pain than did patients treated with transforaminal injection of local anesthetic (7%) or transforaminal injection of saline (19%), intramuscular steroids (21%), or intramuscular saline (13%). Relief of pain was corroborated by significant improvements in function and disability, and reductions in use of other health care. Outcomes were equivalent for patients with acute or chronic radicular pain. Over time, the number of patients who maintained relief diminished. Only some maintained relief beyond 12 months. The proportions of patients doing so were not significantly different statistically between groups. Discussion. Transforaminal injection of steroids is effective only in a proportion of patients. Its superiority over other injections is obscured when group data are compared but emerges when categorical outcomes are calculated. Over time, the proportion of patients with maintained responses diminishes.

Abstract Study Design. Case report. Objective. To report a previously undescribed association between complex regional pain syndrome (CRPS) and surgery for cervical disc protrusion. Summary of Background Data. Although CRPS has been associated with disc protrusion and lumbar spine surgery, there is no record in the literature of a similar association with cervical disc protrusion. Methods. Description of a clinical case. Results. A patient with radicular pain due to cervical disc protrusions underwent posterior foraminotomy, which did not relieve his pain. Within 3-4 weeks, he developed features of CRPS. Review at 16, 22, and 34 months revealed some, but limited, improvement. Conclusions. This case provides circumstantial evidence of a hitherto undescribed association between CRPS and cervical disc protrusion. The mechanism is elusive, but may involve damage to small nerves in or near the intervertebral foramina.

In this exploratory study we evaluated sensitivity and target specificity of sinuvertebral nerve block (SVNB) for the diagnosis of lumbar diskogenic pain. Diskography has been the diagnostic gold standard. Fifteen patients with positive diskography underwent SVNB via interlaminar approach to the posterior aspect of the disk. Success was defined as >/=80% pain reduction or excellent relief of physical restrictions after the block. The sensitivity was 73.3%(95% CI: 50.9%-95.7%). The target specificity was 40%(15.2%-64.8%). The results indicate that SVNB cannot yet replace diskography but encourage future studies to improve its target specificity.

OBJECTIVE: To compare the safety and effectiveness of minimal access posterior lumbar interbody fusion (MAPLIF) with open posterior lumbar interbody fusion (OPLIF) in patients with spondylolisthesis and radicular pain. METHODS: A prospective study was performed of 47 patients with radicular pain resulting from lumbar spondylolisthesis with a slip of less than 50% who underwent either MAPLIF (n = 23) or OPLIF (n = 24). At 12 months after treatment, clinical outcomes were measured using the Short-Form Health Survey 36 and the visual analog score for both leg pain and back pain, and the degree of reduction of spondylolisthesis, restoration of disc height, and presence of fusion were assessed. RESULTS: Both groups were similar in demographic and baseline clinical features. Both exhibited statistically and clinically significant improvements in back pain (OPLIF, 64%; MAPLIF, 78%), and leg pain (88% for both groups). This was corroborated by improvements in social and physical functioning, which were similar for both groups. The reduction of spondylolisthesis and fusion rates were also similar between the 2 groups. MAPLIF patients commenced mobilization sooner, achieved independent mobilization earlier, and had a shorter hospital stay (4 days versus 7 days). CONCLUSION: MAPLIF and OPLIF both reduce leg and back pain and restore function to a similar extent. MAPLIF is as effective as OPLIF in reducing the slip in patients with spondylolisthesis of less than 50%. MAPLIF promotes faster recovery and shortens hospital stay.

BACKGROUND AND OBJECTIVE: In systematic reviews of the reliability of diagnostic tests, no quality assessment tool has been used consistently. The aim of this study was to develop a specific quality appraisal tool for studies of diagnostic reliability. METHODS: Key principles for the quality of studies of diagnostic reliability were identified with reference to epidemiologic principles, existing quality appraisal checklists, and the Standards for Reporting of Diagnostic Accuracy (STARD) and Quality Assessment of Diagnostic Accuracy Studies (QUADAS) resources. Specific items that encompassed each of the principles were developed. Experts in diagnostic research provided feedback on the items that were to form the appraisal tool. This process was iterative and continued until consensus among experts was reached. RESULTS: The Quality Appraisal of Reliability Studies (QAREL) checklist includes 11 items that explore seven principles. Items cover the spectrum of subjects, spectrum of examiners, examiner blinding, order effects of examination, suitability of the time interval among repeated measurements, appropriate test application and interpretation, and appropriate statistical analysis. CONCLUSIONS: QAREL has been developed as a specific quality appraisal tool for studies of diagnostic reliability. The reliability of this tool in different contexts needs to be evaluated.

ABSTRACT Objective. To present two case reports of a rare but devastating injury after image-guided, lumbar transforaminal injection of steroids, and to explore features in common with previously reported cases. Background. Image (fluoroscopic and computed tomography [CT])-guided, lumbar transforaminal injections of corticosteroids have been adopted as a treatment for radicular pain. Complications associated with these procedures are rare, but can be severe. Case Reports. An 83-year-old woman underwent a fluoroscopically guided, left L3-L4, transforaminal injection of betamethasone (Celestone Soluspan). A 79-year-old man underwent a CT-guided, right L3-L4, transforaminal injection of methylprednisolone (DepoMedrol). Both patients developed bilateral lower extremity paralysis, with neurogenic bowel and bladder, immediately after the procedures. Magnetic resonance imaging scans were consistent with spinal cord infarction. There was no evidence of intraspinal mass or hematoma. Conclusion. These cases consolidate a pattern emerging in the literature. Distal cord and conus injury can occur following transforaminal injections at lumbar levels, whether injection is on the left or right. This conforms with the probability of radicular-medullary arteries forming an arteria radicularis magna at lumbar levels. All cases used particulate corticosteroids, which promotes embolization in a radicular artery as the likely mechanism of injury. The risk of this complication can be reduced, and potentially eliminated, by the utilization of particulate free steroids, testing for intra-arterial injection with digital subtraction angiography, and a preliminary injection of local anesthetic.

The effect of neck/shoulder pain on the performance in a hand laterality motor imagery test was studied. Responses to the Cooper and Shepard (1975, Journal of Experimental Psychology: Human Perception and Performance 104 48-56) hand laterality test were explored in twenty-four individuals with chronic non-specific neck pain and twenty-one subjects with chronic neck pain of traumatic origin (whiplash-associated disorder). Twenty-two controls were also included in the study. Digitalised right- or left-hand stimuli were presented at five different stimulus angles (0 degrees, 45 degrees laterally, 90 degrees laterally, 135 degrees laterally, and 180 degrees). The experimental task was to decide the laterality as fast and accurately as possible. The performance, both reaction time (RT) and accuracy, of the two experimental groups was contrasted with that of the control group. The main results revealed that the subjects afflicted with whiplash injury on the average exhibited a faster response pattern than symptom-free healthy controls. Despite their musculoskeletal deficits and experience of pain these volunteers also exhibited a preserved speed-accuracy tradeoff. Longer duration of time with symptoms of neck pain was, moreover, associated with progressively faster RTs. These results point to perceptual learning and may reflect different stages of adaptation to neck pain.

ABSTRACT: BACKGROUND: The clinical consequences of whiplash injuries resulting from a motor vehicle accident (MVA) are poorly understood. Thereby, there is general lack of research on the development of disability in patients with acute and chronic Whiplash Associated Disorders. METHODS: The objective is to describe the design of an inception cohort study with a 1-year follow-up to determine risk factors for the development of symptoms after a low-impact motor vehicle accident, the prognosis of chronic disability, and costs. Victims of a low-impact motor vehicle accident will be eligible for participation. Participants with a Neck Disability Index (NDI) score of 7 or more will be classified as experiencing post-traumatic neck pain and will enter the experimental group. Participants without complaints (a NDI score less than 7) will enter the reference group. The cohort will be followed up by means of postal questionnaires and physical examinations at baseline, 3 months, 6 months, and 12 months. Recovery from whiplash-associated disorders will be measured in terms of perceived functional health, and employment status (return to work). Life tables will be generated to determine the 1-year prognosis of whiplash-associated disorders, and risk factors and prognostic factors will be assessed using multiple logistic regression analysis. DISCUSSION: Little is known about the development of symptoms and chronic disability after a whiplash injury. In the clinical setting, it is important to identify those people who are at risk of developing chronic symptoms. This inception prospective cohort study will provide insight in the influence of risk factors, of the development of functional health problems, and costs in people with whiplash-associated disorders.

STUDY DESIGN: A double-blind, randomized, controlled trial. OBJECTIVE: To determine the clinical effectiveness of therapeutic local anesthetic cervical medial branch blocks with or without steroid in managing chronic neck pain of facet joint origin. SUMMARY OF BACKGROUND DATA: The prevalence of persistent neck pain, secondary to involvement of cervical facet or zygapophysial joints, has been described in controlled studies as varying from 39% to 67%. Intra-articular injections, medial branch nerve blocks, and neurolysis of medial branch nerves have been described in managing chronic neck pain of facet joint origin. METHODS: A total of 120 patients were included, with 60 patients in each of the local anesthetic and steroid groups. All the patients met the diagnostic criteria of cervical facet joint pain by means of comparative, controlled diagnostic blocks, and the inclusion criteria. Group I consisted of medial branch blocks with bupivacaine. Group II consisted of cervical medial branch blocks with bupivacaine and steroid. Numerical pain scores, Neck Disability Index, opioid intake, and work status were evaluated at baseline, 3 months, 6 months, and 12 months. RESULTS: Significant pain relief (>or=50%) and functional status improvement was observed at 3 months, 6 months, and 12 months in over 83% of patients. The average number of treatments for 1 year was 3.5 +/- 1.0 in the nonsteroid group and 3.4 +/- 0.9 in the steroid group. Duration of average pain relief with each procedure was 14 +/- 6.9 weeks in the nonsteroid group, and it was 16 +/- 7.9 weeks in the steroid group. Significant relief and functional improvement was reported for 46 to 48 weeks in a year. CONCLUSION: Therapeutic cervical medial branch nerve blocks, with or without steroids, may provide effective management for chronic neck pain of facet joint origin.

Objective: To evaluate the ability of early smooth pursuit testing to predict chronic whiplash-associated disorders, and to study whether the presence of abnormal smooth pursuit eye movements at one-year follow-up is associated with symptoms at that time.Design: Prospective cohort study with one-year follow-up.Setting: The study was carried out at a university research centre and participants were recruited from emergency units and general practitioners.Subjects: In all, 262 participants were recruited within 10 days from a whiplash injury.Main measures: Smooth pursuit eye movements were tested with electrooculography (EOG) an average of 12 days after a whiplash trauma and again after one year. Analyses of EOG recordings were computerized. Associations between test results both from baseline and one-year tests and self-reported neck pain, headache, neck disability and working ability one year after the car collision were determined.Results: Results of early eye movement tests were not associated with the prognosis. Reduced smooth pursuit performance when tested in static cervical rotation at the one-year follow-up was significantly associated with higher neck pain intensity at that time (regression coefficient 0.8, 95% confidence interval (CI) 0.04-1.5), but the association was too weak for the test to discriminate between recovered participants and those with lasting symptoms.Conclusions: Although reduced smooth pursuit performance at one-year follow-up was associated with persistent neck pain, smooth pursuit eye movement tests are not useful as predictive or diagnostic tests in whiplash-associated disorders.

BACKGROUND: Lumbar facet joints have been implicated as the source of chronic pain in 15% to 45% of patients with chronic low back pain. Various therapeutic techniques including intraarticular injections, medial branch blocks, and radiofrequency neurotomy of lumbar facet joint nerves have been described in the alleviation of chronic low back pain of facet joint origin. OBJECTIVE: The study was conducted to determine the clinical effectiveness of therapeutic local anesthetic lumbar facet joint nerve blocks with or without steroid in managing chronic function-limiting low back pain of facet joint origin. DESIGN: A randomized, double-blind, controlled trial. SETTING: An interventional pain management setting in the United States. METHODS: This study included 60 patients in Group I with local anesthetic and 60 patients in Group II with local anesthetic and steroid. The inclusion criteria was based on the positive response to the diagnostic controlled comparative local anesthetic lumbar facet joint blocks. OUTCOME MEASURES: Numeric pain scores, Oswestry Disability Index, opioid intake, and work status. All outcome assessments were performed at baseline, 3 months, 6 months, and 12 months. RESULTS: Significant improvement with significant pain relief (> 50%) and functional improvement (> 40%) were observed in 82% and 85% in Group I, with significant pain relief in over 82% of the patients and improvement in functional status in 78% of the patients. Based on the results of the present study, it appears that patients may experience significant pain relief 44 to 45 weeks of 1 year, requiring approximately 3 to 4 treatments with an average relief of 15 weeks per episode of treatment. CONCLUSION: Therapeutic lumbar facet joint nerve blocks, with or without steroid, may provide a management option for chronic function-limiting low back pain of facet joint origin.

STUDY DESIGN: A retrospective review. OBJECTIVES: Evaluation of the prevalence of facet or zygapophysial joint pain in chronic spinal pain of cervical, thoracic, and lumbar origin by using controlled, comparative local anesthetic blocks and evaluation of false-positive rates of single blocks in the diagnosis of chronic spinal pain of facet joint origin. SUMMARY OF BACKGROUND DATA: Facet or zygapophysial joints are clinically important sources of chronic cervical, thoracic, and lumbar spine pain. The previous studies have demonstrated the value and validity of controlled, comparative local anesthetic blocks in the diagnosis of facet joint pain, with a prevalence of 15% to 67% variable in lumbar, thoracic, and cervical regions. False-positive rates of single diagnostic blocks also varied from 17% to 63%. METHODS: Five hundred consecutive patients receiving controlled, comparative local anesthetic blocks of medial branches for the diagnosis of facet or zygapophysial joint pain were included. Patients were investigated with diagnostic blocks using 0.5 mL of 1% lidocaine per nerve. Patients with lidocaine-positive results were further studied using 0.5 mL of 0.25% bupivacaine per nerve on a separate occasion. Medial branch blocks were performed with intermittent fluoroscopic visualization, at 2 levels to block a single joint. A positive response was considered as one with at least 80% pain relief from a block of at least 2 hours duration when lidocaine was used, and at least 3 hours or longer than the duration of relief with lidocaine when bupivacaine was used, and also the ability to perform prior painful movements. RESULTS: A total of 438 patients met inclusion criteria. The prevalence of facet joint pain was 39% in the cervical spine [95% confidence interval (CI), 32%-45%]; 34%(95% CI, 22%-47%) in the thoracic pain; and 27%(95% CI, 22%-33%) in the lumbar spine. The false-positive rate with a single block in the cervical region was 45%, in the thoracic region was 42%, and in the lumbar region 45%. CONCLUSIONS: This retrospective review once again confirmed the significant prevalence of facet joint pain in chronic spinal pain.

Abbott Z, Smuck M, Haig A, Sagher O. Irreversible spinal nerve injury from dorsal ramus radiofrequency neurotomy: a case report. Radiofrequency neurotomy (RFN) of the medial branches of the dorsal rami is a successful method of treating facet joint pain. Documented serious complications are rare. We discuss the case of a 33-year-old woman with low back pain (LBP) who sustained a right L5 nerve root injury during RFN. The patient had several months of axial LBP after a motor vehicle collision. She had no relief after anti-inflammatory medications, physical therapy, L5-S1 interlaminar epidural corticosteroid injections, and a right sacroiliac joint injection. She then received bilateral L3 and L4 medial branch and bilateral L5 dorsal ramus blocks with excellent temporary pain relief. Subsequently she underwent bilateral L3 and L4 medial branch and bilateral L5 dorsal ramus RFN. Afterward, she noticed new right leg pain and paresthesias extending throughout the L5 dermatome. Electromyography and magnetic resonance imaging were normal and she was diagnosed with a right L5 sensory radiculopathy. The right leg symptoms were unresponsive to multiple medications. After a successful trial with a spinal cord stimulator, she underwent permanent stimulator placement. Afterward, she had 90% relief of her right leg pain and discontinued all analgesics. Irreversible injury of nontarget nerves is a possible complication of RFN, and can be avoided by following proper procedural protocol.

The purpose of this study was to establish consensus on what factors might predict chronic pain and disability in whiplash injuries following motor vehicle collisions. A Delphi poll involving two rounds of data collection was used as a way to reach consensus among participating experts. Participating experts identified several physical, historical, psychological, and behavioral response factors that they believed were related to the development of chronic pain and related disability in people who have developed whiplash-associated disorders. These included:(1) prior history: previous history of chronic pain;(2) physical factors: high severity of injury, presence of constant neck pain since the accident;(3) psychological factors: belief that pain mean danger and that he or she should avoid exercise, tendency to somatize, to have positive thoughts about pain, catastrophic thinking, low self-efficacy expectancies, and to have symptoms of posttraumatic stress disorders; and (4) behavioral responses to symptoms: avoidance of activities that involve moving the neck through fear of experiencing more pain, and restriction in the use and movement of the neck. These findings may be used to help identify the specific domains that should be assessed in studies seeking to predict which individuals are at risk to develop chronic pain and disability following initial whiplash-associated disorders sustained in crash. If these results are supported by future studies, then they could be used to help develop intervention programs that could prevent long-term pain and disability in whiplash patients who are considered to be at risk to develop chronic disabling pain problems.

BACKGROUND: Although in clinical use, there is only 1 published case report on the efficacy of intraarticular regeneration injection therapy (RIT)(a.k.a. prolotheraphy). This report supports a rationale for future clinical trials of this technique. OBJECTIVE: To assess the efficacy of intraarticular zygapophysial joint RIT in patients with chronic whiplash related neck pain that failed other conservative and interventional procedures. Patients were treated with intraarticular RIT and reassessed over 1 year. DESIGN: Retrospective case review of prospective data. MATERIALS and METHODS: Eighteen consecutive patients were treated with intraarticular prolotherapy by placing 0.5 - 1mL of 20% dextrose solution into each zygapophysial joint, after confirmation of intraarticular location with radiographic contrast, using 25-gauge spinal needles and fluoroscopic guidance. Solution was prepared by diluting D50W with 1% lidocaine. RESULTS: Fifteen patients completed treatment. Three patients had bilateral treatment, leaving 18 sides for analysis. Mean Neck Disability Index (NDI) pre-treatment was 24.71 and decreased post-treatment to 14.21 (2 months), 13.45 (6 months), 10.94 (12 months). Average change NDI=13.77 (p<0.0001) baseline versus 12 months. Symptoms for 14 patients were from motor vehicle accident, of which 13 were in litigation. Patients attending physiotherapy over the course of treatment had better outcomes than those without physiotherapy. Women needed more injections (5.4) than men (3.2) p=0.0003. CONCLUSION: Intraarticular RIT improved pain and function in this case series. The procedure appears safe, more effective than periarticular RIT, and lasted as long, or longer, than those patients with previous radiofrequency neurotomy. Concurrent physiotherapy helped reduce post-procedure neck stiffness. Future trials should consider gender when deciding how many treatments to administer. Litigation was not a barrier to recovery.

: Motor vehicle accidents result in many patients with chronic head and neck pain, some of which meet the criteria for a "whiplash syndrome." The cervical zygapophysial joint synovium, muscular, and ligamentous strains and other anatomical sites are often implicated in the pathophysiology of these cases. Some patients have a characteristic constellation of vague neurological symptoms, often including headache, posterior neck discomfort, dizziness, nausea, and sometimes visual changes. Recently presented research has noted that some patients who have a whiplash-associated disorder have imaging findings consistent with a low-pressure cerebrospinal fluid leak. Some of these patients respond favorably to high-volume epidural blood patch. The following case presentation focuses on the differential diagnosis of a post-traumatic headache syndrome, specific imaging findings, and treatment strategies.