Joshua Levin, MD

All Publications

• Patient Acceptance of Reoperation Risk for Lumbar Decompression Versus Fusion. The spine journal : official journal of the North American Spine Society Pius, A. K., Joseph, Y. D., Mullis, D. M., Koduri, J., Levin, J., Alamin, T. F. 2024

  Abstract

  Lumbar decompression and lumbar fusion are effective methods of treating spinal compressive pathologies refractory to conservative management. These surgeries are typically used to treat different spinal problems, but there is a growing body of literature investigating the outcomes of either approach for patients with lumbar degenerative spondylolisthesis and stenosis. Different operations are associated with different risks and different potential needs for reoperation. Patient acceptance of reoperation rates after spinal surgery is currently not well understood.The purpose of this study is to identify patient tolerance for reoperation rates following lumbar decompression and lumbar fusion surgery.A qualitative and quantitative survey intended to capture information on patient preferences was administered.Written informed consent was obtained from patients presenting to two spinal clinics.Patients were asked their threshold tolerance for reoperation rates in the context of choosing a smaller (decompression) versus larger (fusion) spinal surgery.A survey was administered to patients at two spinal clinics-one surgical and one non-surgical. A consecutive series of new patients over multiple clinic days who agreed to participate in the study and filled out the survey are reported on here. Patients were asked to assess, contemplating a problem that could either be treated with lumbar decompression or lumbar fusion, the level at which 1) the likelihood that needing a repeat surgery within 3-5 years would change their mind about choosing the decompression operation and cause them to choose the fusion operation and then 2) the likelihood of needing a repeat surgery within 3-5 years that would be acceptable to them after the fusion operation. The distribution of patient responses was assessed with histograms and descriptive statistics.Ninety patients were surveyed, and of these, 73 patients (81.1%) returned fully completed questionnaires. The median reoperation acceptance rates after a decompression was <60%, while the median acceptable revision rate when contemplating the fusion surgery was 10%.Patient acceptance for the potential need for revision surgery is higher when considering a decompression compared to a fusion operation. Reoperation risk rates along with the magnitude of the surgical intervention are important considerations in determining patients' surgical preferences. Understanding patient preferences and risk tolerances can aid clinicians in shared decision-making, potentially improving patient satisfaction and outcomes in the several lumbar pathologies which can be ameliorated with either decompression or fusion.

  View details for DOI 10.1016/j.spinee.2024.09.003

  View details for PubMedID 39303829

• Clinical history correlates with lateral atlantoaxial (C1-2) joint edema. A pilot study. Interventional pain medicine Levin, J., Kaufman, M., Yeung, G. 2024; 3 (3): 100434

  Abstract

  Background: Clinical evaluation in the determination of the etiology of axial spine pain is limited.Objective: To determine if a set of three features of the clinical history are indicative of C1-2 joint edema on MRI.Methods: All patients from one physician's practice who had axial cervical spine pain from 2021 to 2023 were evaluated. Cases were defined as those with all 3 of the ASL criteria, defined as Age >65, Superior cervical/suboccipital pain, and exacerbation of pain primarily by Lateral cervical spine rotation. Age-matched controls had axial cervical spine pain without meeting the ASL criteria. Edema around the atlantoaxial joint and/or odontoid was evaluated by STIR MR sequences.Results: The ASL criteria had a sensitivity of 82% [95% CI: 64-100%], specificity of 79%, [95% CI: 63-95%], positive predictive value of 74% [95% CI: 54-94%], and negative predictive value of 86% [95% CI: 72-100%] in diagnosing C1-2 joint edema.Conclusion: A positive ASL criteria is sensitive and specific in the diagnosis of C1-2 joint edema, which may have clinical implications.

  View details for DOI 10.1016/j.inpm.2024.100434

  View details for PubMedID 39502904

• Rates of positive vs negative studies in the spine literature. Interventional pain medicine Levin, S., Levin, J. 2024; 3 (3): 100423

  Abstract

  Background: Accuracy in the interpretation of data, and publication of studies regardless of outcomes are vital to the development of the scientific literature.Objective: To determine the proportion of studies in the spine literature that report positive results.Study design: Review article of studies published in nine major spine, pain, and physical medicine and rehabilitation (PM&R) journals from January 1, 2018-December 31, 2022.Patient sample: Not applicable.Methods: Articles that reported on pain and/or function from 2018 to 2022 in nine major journals were reviewed by two independent evaluators. The articles were graded as either positive or negative based on the authors' own conclusions about their work.Results: Overall, 91% [95% CI 88-94%] of all articles were reported to have positive results. No significant differences were found between the broad categories of spine, pain, and PM&R journals. When comparing different categories of treatments, there were lower rates of positive results from medication/supplement studies (54% [95% CI 27-81%]) compared to studies of spine injections/interventions (95% [95% CI 91-99%]) and those of surgery (100% [95% CI 96-100%]), and a lower rate of positive results from studies on physical treatments (85% [95% CI 75-95%]) compared to those of surgery (100% [95% CI 96-100%]). Studies with placebo controls were less likely to report positive results (60% [95% CI 44-76%]) compared to those that did not use placebo controls (96% [95% CI 94-98%]).Conclusions: Despite the vast majority of studies in the spine literature concluding positive results, the high disease prevalence of spine conditions and the enormous burden on the healthcare system remain.

  View details for DOI 10.1016/j.inpm.2024.100423

  View details for PubMedID 39502901

• A randomized, placebo-controlled trial of long-acting dexamethasone viscous gel delivered by transforaminal injection for lumbosacral radicular pain. Pain Miller, A., Candido, K. D., Knezevic, N. N., Rivera, J., Lunseth, P., Levinson, D. J., Formoso, F., Solanki, D., Tavel, E., Krull, A., Radnovich, R., Burkhead, D., Souza, D., Helm, S., Katz, N., Dworkin, R. H., Cohen, S. P., Rathmell, J. P., Buvanendran, A., Levin, J., Stannard, E., Ambrose, C., Jaros, M., Vought, K., Lissin, D. 2024

  Abstract

  ClinicalTrials.gov Identifier: NCT03372161.

  View details for DOI 10.1097/j.pain.0000000000003287

  View details for PubMedID 38875121

• Rates of positive vs negative studies in the spine literature. Interventional Pain Medicine Levin, S., Levin, J. 2024; 3 (3)
• Systemic steroids for cervical radicular pain: A systematic review. Interventional pain medicine Gall, N., Ghaffari, C., Koduri, J., Dove, C., Levin, J. 2023; 2 (4): 100280

  Abstract

  Determine the effectiveness of systemic steroids for the treatment of cervical radicular pain.We identified articles from two electronic databases (PubMed and Ovid Medline) and previously known articles.We combined (using the Boolean Operator "AND") the following search terms: "Steroid* and Cervical Radic*" or "Steroid* and Cervicobrachialgia". We applied the search to PubMed and Ovid Medline research databases for all studies up February 11, 2022. We included all published articles involving cervical radicular pain treated with systemic steroids among adult users (≥18 years old). We defined systemic steroids as steroid medication administered into the body excluding epidural or intra-articular injections. We excluded reviews and editorials.Information extracted from each study included: (1) study design; (2) characteristics of trial participants; (3) diagnostic criteria; (4) treatment intervention protocol; (5) outcome measure; and (6) follow-up time. Outcomes included the neck disability index (NDI) and patient reported pain.842 publications were identified, 7 were suitable for inclusion. The only level one study comparing oral steroid to placebo reported greater improvements of NDI (35.7 ± 21.4 versus 12.9 ± 10.2, P < 0.001) and NPRS (4.4 ± 2.7 versus 1.6 ± 1.2, P < 0.001), and higher success rates (76% [95% CI: 60-92%] vs 30% [95% CI: 14-46%]) in the oral steroid group compared to the placebo group. The only level one study comparing paraspinal intramuscular (IM) versus interlaminar (IL) epidural steroids reported worse outcomes in the IM group with a success rate of 35% [95% CI: 13-58%] at 1 week and 12% [95% CI: 0-27%] at one year in the IM group, compared to 76% [95% CI: 60-92%] at 1 week (p = 0.04) and 68% [95% CI: 50-86%] at one year (p = 0.0004) in the IL group (P < 0.0004). The Cochrane Risk of Bias Tool and GRADE system was used to assess bias and rate the overall evidence quality.Very limited evidence exists supporting treatment of cervical radicular pain with systemic steroids. Oral steroids can be considered as a reasonable conservative option based on one RCT, whereas IM steroids may be inferior to epidural steroids based on another RCT. Additional higher quality studies are needed.

  View details for DOI 10.1016/j.inpm.2023.100280

  View details for PubMedID 39239209

  View details for PubMedCentralID PMC11373080

• Intraosseous basivertebral nerve ablation: Pooled long-term outcomes from two prospective clinical trials. Interventional pain medicine Smuck, M., Truumees, E., Macadaeg, K., Jaini, A. M., Chatterjee, S., Levin, J. 2023; 2 (2): 100256

  Abstract

  Vertebrogenic pain is an established source of anterior column chronic low back pain (CLBP) resulting from damaged vertebral endplates with pain signals transmitted by the basivertebral nerve (BVN). Type 1 or Type 2 Modic changes on magnetic resonance imaging (MRI) are objective biomarkers for vertebrogenic pain. Radiofrequency ablation of the BVN (BVNA) has demonstrated both efficacy and effectiveness for the treatment of vertebrogenic pain in two randomized trials. Here, we report 3-year aggregate results from two prospective studies of BVNA-treated patients.Pooled results at 3 years post-BVNA are reported for two studies with similar inclusion/exclusion criteria and outcomes measurements: 1) a prospective, open label, single-arm follow-up of the treatment arm of a randomized controlled trial (RCT) comparing BVNA to standard care (INTRACEPT Trial), and 2) a prospective, open label, single cohort long-term follow-up study of BVNA-treated patients. Paired datasets (baseline and 3-years) for mean changes in Oswestry disability index (ODI) and numeric pain scores (NPS) were analyzed using a two-sided t-test with a 0.05 level of significance.There were 95/113 (84%) BVNA patients who completed a 3-year visit across 22 study sites. At baseline, 71% of patients reported back pain for ≥5 years, 28% were taking opioids, 34% had spinal injections in the prior 12 months, and 14% had prior low back surgery. Pain and functional improvements were significant at 3 years with a mean reduction in NPS of 4.3 points from 6.7 ​at baseline (95% CI 3.8, 4.8; p<0.0001) and a mean reduction in ODI of 31.2 points from 46.1 ​at baseline (95% CI 28.4, 34.0; p<0.0001). Responder rates, using minimal clinically important differences of ≥15-points for ODI and ≥50% reduction in NPS from baseline to three years, were 85.3% and 72.6%, respectively (combined response 69.5%), with 26.3% of patients reporting 100% pain relief at 3 years. There was a 74% reduction in the use of opioids and 84% reduction in the use of therapeutic spinal interventions from baseline to 3 years. There were no serious device or device-procedure related adverse events reported through three years.Intraosseous BVNA demonstrates statistically significant, clinically meaningful, and durable improvements in pain and function through 3 years in patients with primary vertebrogenic low back pain. BVNA-treated patients significantly reduced opioid use and interventions for low back pain.

  View details for DOI 10.1016/j.inpm.2023.100256

  View details for PubMedID 39238665

  View details for PubMedCentralID PMC11373002

• Is a history of episodic low back pain an indicator of Modic changes? Interventional pain medicine Levin, J., Schirmer, D., Garcia, R., Levi, D. 2023; 2 (1): 100239

  Abstract

  Background: Prior work demonstrated that a history of episodic low back pain was highly indicative of discogenic pain. Recently, there has been more focus on vertebrogenic pain, however little is known about the clinical features of this condition.Purpose: To determine if a history of severe episodic low back pain correlates with Modic endplate changes on lumbar spine magnetic resonance imaging (MRI), presumed to be a marker of vertebrogenic pain.Study design: /setting: Retrospective, observational, in vivo study of consecutive patients at outpatient Physical Medicine & Rehabilitation clinics at a single academic spine center.Patient sample: Consecutive patients who received a lumbar spine MRI between January 1, 2020, and December 31, 2020.Methods: A retrospective chart review identified patients who received a lumbar spine MRI in 2020. Chart review then determined if patients had a history of episodes of low back pain lasting at least 2 days, or if they had non-episodic low back pain (pain beginning with a gradual onset or after a specific event with continuous symptoms for >3 months). Patients were excluded if they had prior lumbar spine surgery, radicular leg pain without low back pain, indeterminate presentations based on chart review, acute spine fractures, or metastatic spine lesions. For the primary analysis, the MRIs were reviewed and were dichotomized into positive (having for either type 1 or type 2 Modic changes at any level) or negative (no Modic changes at any level).Results: A total of 111 patients were analyzed. Inter-rater reliability for determining whether a patient's low back pain was episodic was strong (kappa​=​0.83), as was inter-rater reliability for determining if a patient had any levels with type 1 or type 2 Modic changes (kappa​=​0.81). Seventy-one out of 111 patients had type 1 and/or type 2 Modic changes at one or more spinal levels. The sensitivity of the test (episodic vs non-episodic low back pain) in finding patients with Modic changes was 20% and the specificity was 70%. The diagnostic confidence odds were 1.2, with a diagnostic confidence of 55%. Subgroup analyses for type 1 Modic changes, and for type 2 Modic changes, showed similar values.Conclusions: A history of episodic low back pain is not a strong indicator for a vertebrogenic etiology.

  View details for DOI 10.1016/j.inpm.2023.100239

  View details for PubMedID 39239605

• Safety of dexamethasone in transforaminal epidural steroid injections: A case of temporary paraplegia caused by injection of lidocaine and dexamethasone into a lumbar radiculomedullary artery, with no neurologic sequelae. Interventional pain medicine Levi, D., Horn, S., Murphy, J., Levin, J. 2023; 2 (1): 100240

  View details for DOI 10.1016/j.inpm.2023.100240

  View details for PubMedID 39239597

• The type 2 high intensity zone: Two cases of axial low back pain in the setting of high T1 and high T2 signal in the posterior annulus. Interventional pain medicine Ghaffari, C., Heit, J., Levin, J. 2022; 1 (4): 100131

  View details for DOI 10.1016/j.inpm.2022.100131

  View details for PubMedID 39238855

  View details for PubMedCentralID PMC11372972

• Results of lumbar transforaminal epidural steroid injections based on the physician referral source. Interventional pain medicine Levin, J., Li, W., Gall, N., Chan, J., Caragea, M., Huynh, L., Koltsov, J., Smuck, M. 2022; 1 (3): 100114

  Abstract

  Background: Many patients who receive lumbosacral transforaminal epidural steroid injections (TFESIs) are referred for the injection from a physician who does not perform the procedure.Purpose: To compare success rates of fluoroscopically guided lumbosacral TFESIs in patients who had a clinical evaluation and recommendation for the injection by a fellowship-trained spine specialist who routinely performs ESIs (Group A), vs those who had a clinical evaluation by a fellowship-trained spine specialist who referred the patient for the procedure to be done by a different physician (Group B).Study design/setting: Retrospective, observational, in vivo study of consecutive patients. Patient.Sample: Patients undergoing lumbosacral TFESIs at a single outpatient academic spine center. Outcome.Measures: Numeric Rating Scale (NRS) pain score improvement.Methods: Current procedural terminology (CPT) codes were used to search all consecutive patients who received a lumbosacral TFESI between September 2019 and September 2020. All patients with pre- and post-injection NRS pain scores within 60 days of the injection were included in the analysis.Results: A total of 230 TFESIs were analyzed, 151 in Group A, and 79 in Group B. The primary outcome was defined as > 50% improvement in the NRS pain score. 39% [95% CI: 33, 45%] of all patients who received a lumbosacral TFESI achieved a successful outcome. There were better results in Group A with a 47% [95% CI: 39, 55%] success rate compared to a 23% [95% CI: 14, 32%] success rate in Group B. Group A also had a higher proportion of patients who achieved at least 80% pain relief (26% [95% CI: 19, 33%]) compared to Group B (10% [95% CI: 3, 17%]). History of prior surgery did not significantly affect outcomes.Conclusion: This retrospective study demonstrated a higher success rate from lumbosacral TFESIs when patients were referred for the injection by a physician who performs ESIs.

  View details for DOI 10.1016/j.inpm.2022.100114

  View details for PubMedID 39238527

• Yes but no. Interventional pain medicine Levin, J. 2022; 1 (2): 100110

  View details for DOI 10.1016/j.inpm.2022.100110

  View details for PubMedID 39239379

• Retrospective analysis of cervical transforaminal versus interlaminar epidural steroid injections. Interventional pain medicine Levin, J., Chan, J., Gall, N., Koltsov, J., Huynh, L. 2022; 1 (2): 100102

  Abstract

  Background: Several studies have compared outcomes from lumbar epidural steroid injections (ESIs) based upon technique (transforaminal (TF) vs interlaminar (IL) vs caudal). However, little on this topic has been reported in the cervical spine, and results have been conflicting.Purpose: To compare success rates of fluoroscopically-guided cervical TFESIs vs ILESIs.Study design/setting: Retrospective, observational, in vivo study of consecutive patients at outpatient Physical Medicine & Rehabilitation clinics at a single academic spine center.Patient sample: Consecutive patients who received a cervical TF or IL ESI between January 2010 and October 2018.Outcome measures: NRS pain scores within 60 days of the ESI.Methods: Current procedural terminology (CPT) codes were used to search all consecutive patients at a single outpatient academic spine center who received a cervical TF or IL ESI between January 2010 October 2018. All patients with pre and post injection NRS pain scores within 60 days of the injection were included in the analysis.Results: A total of 178​TF and 185 ILESIs were analyzed. Success was defined as ≥ 50% improvement in NRS pain score. 52% [95% CI: 47 - 57%] of all patients receiving a cervical ESI achieved a successful outcome. There was a strong trend towards better results in the ILESI group with 59% [95% CI: 52 - 66%] of patients achieving at least 50% pain relief compared to 46% [95% CI: 39 - 53%] in the TF group. A higher proportion of patients in the IL group obtained at least 80% pain relief (37% [95% CI: 30 - 44%]) compared to those in the TF group (17% [95% CI: 11 - 23%]). Post-procedure median NRS pain scores, and improvement in median NRS pain scores were better in the ILESI group compared to the TFESI group (p<0.001).Conclusion: This retrospective study demonstrated better results in the cervical ILESI group compared to the cervical TFESI group.

  View details for DOI 10.1016/j.inpm.2022.100102

  View details for PubMedID 39239365

• Attempted aspiration of a symptomatic lumbar juxtafacet cyst resulting in improvement of acute onset radiculopathy with progressive motor weakness. Interventional pain medicine Su, S., Mitsuya, Y., Schirmer, D., Levin, J. 2022; 1 (2): 100101

  View details for DOI 10.1016/j.inpm.2022.100101

  View details for PubMedID 39239377

• Thoracic transforaminal epidural steroid injection for management of thoracic spine pain: A multicenter cross-sectional study of short-term outcomes. Interventional pain medicine Levin, J., Chan, J., Huynh, L., Smuck, M., Koltsov, J., Kesikburun, B., Wagner, G. E., Caragea, M., Kuo, K., McCormick, Z. L., Schneider, B., Berlin, E., Kennedy, D. J., Kesikburun, S. 2022; 1 (1): 100004

  Abstract

  Thoracic transforaminal epidural steroid injections (TFESIs) are procedures performed for the treatment of thoracic spine pain (TSP). The literature on these interventions is sparse.To report outcomes of thoracic TFESIs for TSP indications.Multicenter, retrospective, cross-sectional cohort study.Consecutive patients receiving thoracic TFESIs at three academic spine centers.The primary outcome was the proportion of patients reporting at least 50% improvement in NRS pain score at short-term follow-up (>1 week, <3 months post-injection).A chart review was performed of consecutive patients who underwent a thoracic TFESI over a 4- to 10-year time period at three academic spine centers and had reported an NRS pain score at short-term follow-up.Overall, 19/64 patients (30% [95% CI 20-42%]) experienced ≥50% relief following the injection at a median 22 days follow-up. 42% [95% CI 31-54%] experienced at least a 2-point improvement in NRS score. There was a slight improvement in median NRS scores from pre-to post-procedure of -1 (IQR -3, 0), from 6/10 to 5/10 (p ​< ​0.001). The success rate (≥50% pain relief) was 36% [95%CI 22-52%] in those with a disc herniation as compared to 21% [95%CI 10-40%]) in those with degenerative stenosis; however, the difference did not reach statistical significance. There was a trend towards a greater success rate in those who were employed vs. unemployed (43% [95% CI 27-61%] vs. 19% [95% CI 9-36%]).This is the largest series reporting outcomes from thoracic TFESI to date. Overall, the observed success rate was low compared to known success rates associated with TFESI for the treatment of pain at cervical and lumbar spinal regions.

  View details for DOI 10.1016/j.inpm.2021.100004

  View details for PubMedID 39301446

  View details for PubMedCentralID PMC11411569

• Improving environmental sustainability in outpatient clinics: Lessons from a waste audit JOURNAL OF CLIMATE CHANGE AND HEALTH Taylor, A., Levin, J., Chan, J., Lee, M., Kasitinon, D., Miller, E., Fox, P. 2021; 4

  View details for DOI 10.1016/j.joclim.2021.100070

  View details for Web of Science ID 001266916600022

• Extensor Digitorum Brevis Bulk and Associations with Fibular Motor Nerve Conduction Amplitude. PM & R : the journal of injury, function, and rehabilitation Levin, J., Lowe, A., Tamura, L., Miller, E., Koltsov, J., Kenrick, A., Barrette, K., Richardson, J. 2021

  Abstract

  INTRODUCTION: Prior work demonstrates that fibular compound motor action potential (CMAP) amplitude <4.0 mV predicts impairment of ankle proprioceptive precision and increased fall risk. Extensor digitorum brevis (EDB) inspection may present a simple clinical surrogate for CMAP amplitude.OBJECTIVE: 1) To estimate the inter-rater reliability of assessment of EDB bulk. 2) To determine whether inspection of EDB bulk is associated with fibular CMAP amplitude.DESIGN: Independently and prior to nerve conduction studies (NCS), two investigators graded EDB bulk. Next, fibular NCS were completed.SETTING: An academic center's outpatient Physical Medicine & Rehabilitation EMG clinics.PARTICIPANTS: 52 adult participants (102 feet) PREDICTOR: EDB bulk graded as 1)normal, 2)diminished, or 3)atrophied MAIN OUTCOME MEASURES: 1. Inter-rater reliability of assessment of EDB bulk. 2. Mean fibular CMAP amplitude. 3. A binary measure of fibular CMAP amplitude above or below a 4.0 mV threshold.RESULTS: Inter-rater reliability of EDB bulk grading was moderate (kappa: 0.65 [95% C.I. 0.48 - 0.82]). The mean CMAP value was 5.9 ±2.2 mV when bulk was normal, 3.4 ±2.1 mV when diminished, and 0.6 ±0.9 mV when atrophied. A multivariable analysis demonstrated that EDB bulk, distal symmetric polyneuropathy (DSP), and lumbar radiculopathy were all associated with CMAP amplitude. The sensitivity and specificity of grading muscle bulk as normal vs abnormal in detecting CMAP amplitude above or below 4.0mV were 0.86 [95% C.I. 0.78 - 0.94] and 0.71 [95% C.I. 0.54 - 0.88], respectively. An atrophied EDB was a highly specific indicator that CMAP amplitude was abnormal (<4.0 mV) in 100% of cases (8/8).CONCLUSIONS: EDB bulk was associated with fibular CMAP amplitude. Atrophy was a highly specific indicator for CMAP amplitude below 4.0 mV. Evaluation of EDB bulk may represent a quick and easy clinical surrogate marker for CMAP amplitude and distal neuromuscular impairment.

  View details for DOI 10.1002/pmrj.12608

  View details for PubMedID 33876583

• Contrast Flow Patterns Based on Needle Tip Position During Cervical Transforaminal Epidural Injections. PM & R : the journal of injury, function, and rehabilitation Levin, J. n., Levi, D. n., Gall, N. n., Horn, S. n., Smuck, M. n. 2021

  Abstract

  Few studies have evaluated the effect of final needle position on contrast flow patterns during the performance of cervical transforaminal epidural steroid injections (TFESIs).Analyze fluoroscopically-guided cervical TFESI contrast flow patterns based upon final needle tip position.Retrospective, observational in vivo study.Outpatient private practice PM&R spine clinic.100 consecutive patients undergoing cervical TFESIs.Cervical TFESIs.Categories of contrast flow patterns including epidural, intraforaminal, "sufficient to inject," and "predominantly epidural and/or intraforaminal," based upon final needle tip position.Two independent observers reviewed images from 100 consecutive patients and classified injectate flow patterns stratified by needle tip position. The inter-rater reliability for all categories of interest was moderate, with kappa values from 0.61 to 0.76. More medially placed needles (middle third and lateral third of the articular pillars) resulted in higher rates of epidural contrast flow (75% [95% CI: 56% - 94%] and 60% [95% CI: 47% - 73%]) compared to needles placed lateral to the articular pillars (26% [95% CI: 8% - 44%]), and higher rates of "predominantly epidural and/or intraforaminal" flow patterns with needles placed in the middle one third (75% [95% CI: 56% - 94%]) and lateral one third of the articular pillars (47% [95% CI: 34% - 60%]) compared to flow patterns when needles were placed lateral to the articular pillars (17% [95% CI: 2% - 32%]). No needles were placed in the medial third of the articular pillars.More medially placed needle tips result in more optimal flow patterns during cervical TFESIs. The importance of this finding is unknown as clinical outcomes were not measured. This article is protected by copyright. All rights reserved.

  View details for DOI 10.1002/pmrj.12597

  View details for PubMedID 33773077

• Thoracic Transforaminal Epidural Steroid Injection for Management of Thoracic Spine Pain: A Multicenter Study of Short-Term Outcomes Interventional Pain Medicine Levin, J., Chan, J., Huynh, L., Kesikburun, B., Wagner, G., Caragea, M., Kuo, K., McCormick, Z., Schneider, B., Berlin, E., Smuck, M., Kennedy, D., Kesikburun, S. 2021; 1 (1)
• Results of Cervical Epidural Steroid Injections Based on the Physician Referral Source. Interventional Pain Medicine Levin, J., Gall, N., Chan, J., Huynh, L., Kennedy, D., Koltsov, J., Smuck, M. 2021; 1 (1)
• Neuromuscular Ultrasound for Myeloid Sarcoma Affecting the Sciatic Nerve: A Case Report. Ultraschall in der Medizin (Stuttgart, Germany : 1980) Kim, J. n., Park, H. J., Levin, J. n., Won, S. J. 2020

  View details for DOI 10.1055/a-1288-0256

  View details for PubMedID 33142332

• Modification of the Cervical Transforaminal Epidural Steroid Injection Technique Based Upon the Anatomic Angle of the Superior Articular Process on MRI. Pain medicine (Malden, Mass.) Levi, D. n., Horn, S. n., Murphy, J. n., Smuck, M. n., Levin, J. n. 2020

  Abstract

  A modification of the conventional technique for cervical transforaminal epidural steroid injection (CTFESI) has been developed. This technique may, theoretically, decrease the likelihood of the needle encountering the vertebral artery and spinal nerve. The approach uses angle measurements of the superior articular process ventral surface from the patient's axial MRI as a guide for fluoroscopic set-up and needle trajectory. This report aims to compare contrast flow patterns of the modified approach with those of the conventional technique.Retrospective chart review and prospective blinded analysis of contrast flow patterns. Setting. Outpatient interventional physiatry practice.A retrospective blinded qualitative review of fluoroscopic images was performed to compare contrast flow patterns of CTFESIs performed using the modified approach with those using the conventional technique. A detailed description of the modified approach is provided in this report.Ninety-seven CTFESI procedures were used for flow analysis. The modified approach resulted in a statistically significant greater percentage of injections with epidural flow: 69% [95% CI = 57-82%] modified approach vs. 42% [95% CI = 28-56%] conventional approach. The modified technique also showed a statistically significant higher percent of injections categorized as having an ideal flow pattern, that of predominate epidural and/or intraforaminal flow: 65% [95% CI = 52-78%] vs. 27% [95% CI = 14-40%].A modification of the conventional CTFESI technique, developed for the purpose of improved safety, may provide superior contrast flow patterns when compared to the conventional approach.

  View details for DOI 10.1093/pm/pnaa162

  View details for PubMedID 32683452

• Incidence of Extravascular Perivertebral Artery Contrast Flow During Cervical Transforaminal Epidural Injections. Pain medicine (Malden, Mass.) Levin, J. n., Mohan, M. n., Levi, D. n., Horn, S. n., Smuck, M. n. 2020

  Abstract

  During a cervical transforaminal epidural injection, injectate flows along the path of least resistance. Given the proximity of the vertebral artery to the intervertebral foramen, injected contrast may flow along the external wall of the artery. The incidence of this contrast flow pattern during cervical transforaminal epidural injections is unknown.To determine the incidence of extravascular perivertebral artery contrast flow patterns during cervical transforaminal epidural injections.Retrospective, observational, in vivo study.Patients receiving cervical transforaminal epidural injections at a single outpatient spine clinic.The presence or absence of extravascular perivertebral artery contrast flow.The saved images from 100 consecutive patients were reviewed by two independent observers and classified with or without extravascular perivertebral artery contrast flow. The incidence was determined and kappa was used to examine inter-rater reliability. All disagreements were reviewed, and the final classification was determined by consensus.The inter-rater reliability was moderate, with a kappa value of 0.69. The incidence of extravascular perivertebral artery contrast flow patterns was 49% by consensus. No statistically significant differences in incidence were present when comparing three different final needle tip positions.During a cervical transforaminal epidural injection, an extravascular perivertebral artery contrast flow pattern is frequently encountered. This includes flow along the exiting nerve and then around the vertebral artery, as suggested by this study. Although this contrast pattern does not represent an intravascular injection into the vertebral artery, practitioners should remain cautious to exclude intravascular needle placement before injecting medication.

  View details for DOI 10.1093/pm/pnaa050

  View details for PubMedID 32249302

• Ultrasonographic measurement of the cross-sectional area of the axillary nerve MUSCLE & NERVE Yoon, J., Park, J., Levin, J., Roh, E. Y., Park, H., Won, S. 2019; 60 (1): 95–98

  View details for DOI 10.1002/mus.26480

  View details for Web of Science ID 000471831900023

• Intra-articular Steroids vs Saline for Lumbar Z-Joint Pain: A Prospective, Randomized, Double-Blind Placebo-Controlled Trial PAIN MEDICINE Kennedy, D. J., Fraiser, R., Zheng, P., Huynh, L., Levin, J., Smuck, M., Schneider, B. J. 2019; 20 (2): 246–51

  View details for DOI 10.1093/pm/pny225

  View details for Web of Science ID 000460637900005

• Pain and Functional Outcomes After Sacroiliac Joint Injection with Anesthetic and Corticosteroid at Six Months, Stratified by Anesthetic Response and Physical Exam Maneuvers. Pain medicine (Malden, Mass.) Schneider, B. J., Ehsanian, R. n., Huynh, L. n., Levin, J. n., Zheng, P. n., Kennedy, D. J. 2019

  Abstract

  To evaluate sacroiliac joint (SIJ) injection outcomes with local anesthetic and corticosteroid.Prospective cohort.Single academic medical center.Thirty-four patients referred for SIJ injection with a clinical diagnosis of SIJ pain underwent injections with 1:1 mixture of 2% lidocaine and triamcinolone 40 mg/mL. Pain provocation physical exam (PE) maneuvers were recorded immediately before and after injection. Outcome measures at two to four weeks and six months included pain numeric rating scale (NRS) and Oswestry Disability Index (ODI).For the analysis of outcomes by the overall group (not stratified by PE and/or anesthetic block), a 58.8% (95% confidence interval [CI] = +/-16.5%) ≥2 NRS reduction, a 32.4% (95% CI = +/-15.7%) ≥50% NRS reduction, and a 38.2% (95% CI = +/-16.3%) ≥30% ODI reduction were observed at two to four weeks, with similar improvements at six months. Outcomes stratified based on pre-injection PE did not reveal significant differences at either time point. The stratification based on the presence of 100% postinjection anesthetic response demonstrated a significant difference at two to four weeks for ≥50% NRS improvement. The true positive/true negative group (TP/TN) stratification demonstrated a significant difference for ≥50% NRS improvement at two to four weeks, whereas six-month outcomes for TP/TN demonstrated significant differences for ≥50% NRS and ≥30% ODI improvement. An increased injection response was observed with stratification of patients more likely to have true SIJ pain (i.e., TP), with TP/TN stratification demonstrating a 75% (95% CI = +/-30.0%) ≥2 NRS improvement and a 62.5% (95% CI = +/-33.5%) improvement of ≥50% NRS and ≥30% ODI for the TP group at two to four weeks, with similar results at six months.SIJ steroid injection based on referral clinical diagnosis is unlikely to demonstrate true injection efficacy, and more specific selection criteria are warranted.

  View details for DOI 10.1093/pm/pnz111

  View details for PubMedID 31106837

• Intra-articular Sacroiliac Joint Needle Placement: Ultrasound, Fluoroscopy, and the Criterion Standard. American journal of physical medicine & rehabilitation Schneider, B. J., Ehsanian, R. n., Levin, J. n., Huynh, L. n., Kennedy, D. J., McCormick, Z. L. 2019

  View details for DOI 10.1097/PHM.0000000000001288

  View details for PubMedID 31393271

• Validity of Physical Exam Maneuvers in the Diagnosis of Sacroiliac Joint Pathology. Pain medicine (Malden, Mass.) Schneider, B. J., Ehsanian, R. n., Rosati, R. n., Huynh, L. n., Levin, J. n., Kennedy, D. J. 2019

  Abstract

  A combination of physical examination maneuvers is currently considered necessary to help predict who will respond to injections in the sacroiliac joint. However, the literature on this topic currently consists of conflicting studies, with one showing the value of a combination of exam maneuvers and the other showing no real value.To determine the diagnostic validity of sacroiliac joint (SIJ) physical exam maneuvers using anesthetic intra-articular injection as a reference standard.A single institution prospective study.Patients with the clinical diagnosis of SIJ pain and referred for SIJ injection were enrolled.Numeric rating scale (NRS) to assess pain intensity.Participants underwent fluoroscopically guided SIJ intra-articular injection with 1 cc of 2% lidocaine and 1 cc of triamcinolone 40 mg. Patients' pain was assessed via 0-10 NRS pre-injection and immediately postinjection to determine positive anesthetic response to the injection. Six physical exam maneuvers (thigh thrust, Geanslen's test, FABER test, distraction test, compression test, and sacral thrust) were performed pre-injection and 15 minutes postinjection. The results of these SIJ physical exam maneuvers were evaluated singly and in combinations for diagnostic power in relation to a positive anesthetic response (>80% relief) to the injection. No association was found between a single SIJ physical exam maneuver or combination of maneuvers and anesthetic response to the injection.In this cohort, patient physical exam maneuvers to identify intra-articular SIJ pain did not demonstrate diagnostic value when compared with the reference standard of an intra-articular anesthetic block.

  View details for DOI 10.1093/pm/pnz183

  View details for PubMedID 31393577

• Intra-articular Steroids vs Saline for Lumbar Z-Joint Pain: A Prospective, Randomized, Double-Blind Placebo-Controlled Trial. Pain medicine (Malden, Mass.) Kennedy, D. J., Fraiser, R., Zheng, P., Huynh, L., Levin, J., Smuck, M., Schneider, B. J. 2018

  Abstract

  Objective: To determine if intra-articular (IA) injection of corticosteroids is effective in reducing the need for radiofrequency ablation (RFA) in those with dual comparative medial branch block (MBB)-confirmed lumbar z-joint pain.Design: This was a randomized, double blind, placebo-controlled study.Setting: Two academic medical centers.Subjects: Fifty-six consecutive subjects who had ≥80% pain relief during an initial screening MBB were recruited.Methods: Patients received a second confirmatory MBB and concurrent IA injection of either corticosteroid or saline per randomization. Twenty-nine of 56 received intra-articular corticosteroid (triamcinolone 20mg), of whom 24 also had a positive confirmatory MBB per Spine Interventional Society guidelines, with ≥80% pain relief from both MBBs. Twenty-seven of 56 received IA saline into the z-joint during the confirmatory MBB, of whom 22 also had a positive confirmatory MBB. The primary outcome measure was the categorical need for RFA due to insufficient pain relief with intra-articular injection, and the secondary outcome was time to RFA.Results: There was no statistically significant difference in the need for an RFA between the groups (16/24 steroid, 67%, 95% confidence interval [CI]=47-82%) vs 15/22 saline (68%, 95% CI=47-84%, P=1.00). The average time to RFA was also not different, at 6.00weeks for steroids vs 6.55weeks for saline (P=0.82).Conclusions: Intra-articular corticosteroids were not effective in reducing the need for or the time to a radiofrequency ablation of the medial branches in those with dual MBB-confirmed lumbar z-joint pain.

  View details for PubMedID 30541041

• The Value of Electrodiagnostic Studies in Predicting Treatment Outcomes for Patients with Spine Pathologies. Physical medicine and rehabilitation clinics of North America Barrette, K., Levin, J., Miles, D., Kennedy, D. J. 2018; 29 (4): 681-687

  Abstract

  The utility of electrodiagnostic testing for spine pathologies varies based on the underlying suspected pathology. This article reviews the data on electrodiagnostic testing for common spine pathologies, with a specific focus on the prognostic data with regard to treatment outcomes. This information is placed into context of diagnostic confidence, which is derived from the combination of disease prevalence and the sensitivity and specificity of a test.

  View details for DOI 10.1016/j.pmr.2018.06.004

  View details for PubMedID 30293623

• Corticosteroid Injections Into Lumbar Facet Joints: A Prospective, Randomized, Double-Blind Placebo-Controlled Trial AMERICAN JOURNAL OF PHYSICAL MEDICINE & REHABILITATION Kennedy, D. J., Huynh, L., Wong, J., Mattie, R., Levin, J., Smuck, M., Schneider, B. J. 2018; 97 (10): 741–46

  Abstract

  Corticosteroid injections into the intra-articular zygapophysial (z-joints) are frequently used to treat this cause of low back pain. No studies have been done on the efficacy of intra-articular corticosteroids in those with z-joint pain confirmed by dual comparative medial branch blocks.The aim of the study was to determine whether an injection of a corticosteroid into lumbar z-joints is effective in reducing pain and the need for radiofrequency neurotomy.This is a double-blind, prospective, randomized, placebo-controlled trial. The study was conducted in Academic Medical Center. Twenty-eight subjects with z-joint pain confirmed by medial branch blocks were included in the study. Subjects with confirmed z-joint pain via dual comparative medial branch block were randomized to receive either intra-articular corticosteroid (triamcinolone 20 mg) or saline via fluoroscopic guided injection.No statistically significant difference in the need for radiofrequency neurotomy (radiofrequency neurotomy) between the groups, with 75% (95% confidence interval = 50.5%-99.5%) of the saline group vs. 91% (95% confidence interval = 62.3%-100%) of the corticosteroid group receiving radiofrequency neurotomy. There is no difference in mean time to radiofrequency neurotomy between saline (6.1 wks) and corticosteroid (6.5 wks) groups. There is a need for radiofrequency neurotomy.Corticosteroid injections into the lumbar z-joints were not effective in reducing the need for radiofrequency neurotomy of the medial branches in those with z-joint pain confirmed by dual comparative medial branch blocks.

  View details for PubMedID 29734232

• Is a History of Severe Episodic Low Back Pain an Indicator of a Discogenic Etiology? PAIN MEDICINE Levi, D., Carnahan, D., Horn, S., Levin, J. 2018; 19 (7): 1334–39

  Abstract

  To determine if a history of severe episodic low back pain (LBP) correlates with positive discography.A retrospective chart review identified patients undergoing discography from January 2012 through February 2016. The review determined if the patient's LBP began or continued with severe disabling episodes (lasting a minimum of two days). A gradual onset or initiating event with continuous symptoms was considered a nonepisodic history. Patients were excluded for unclear record, workers' compensation, litigation, prior lumbar surgery, radiologic instability, or indeterminate discography.Seventy-eight patients underwent discography. Thirty-nine patients were included, 31 of which had positive discograms. Eight had negative discograms. Nineteen patients had a history of episodic LBP, and 20 had no history of episodic LBP. Of those 19 with a history of episodic LBP, 18 had positive discography and one had negative discography. Of those with no history of episodic LBP, 13 had positive discography and seven had negative discography. Using the historical finding of severe episodic LBP as a test for discogenic source of LBP, the sensitivity is 58% (95% confidence interval [CI] = 41-75%) and the specificity is 88% (95% CI = 65-100%). The likelihood ratio is 4.7 (95% CI = 0.72-30). The positive predictive value (PPV) is 95% (95% CI = 72-100%). The PPV is based upon a prevalence of 79% (discogram positive) in our sample of patients considering fusion surgery. The diagnostic confidence odds are 18.2, with a diagnostic confidence of 95%.A positive history of severe episodic LBP may be a strong indicator for a discogenic etiology.

  View details for DOI 10.1093/pm/pnx147

  View details for Web of Science ID 000444271900005

  View details for PubMedID 29016955

• The Value of Electrodiagnostic Studies in Predicting Treatment Outcomes for Patients with Spine Pathologies. Physical Medicine and Rehabilitation Clinics of North America Barrette, K., Levin, J., Miles, D., Kennedy, D. 2018

  View details for DOI 10.1016/j.pmr.2018.06.004

• Does Immediate Pain Relief After an Injection into the Sacroiliac Joint with Anesthetic and Corticosteroid Predict Subsequent Pain Relief? Pain medicine (Malden, Mass.) Schneider, B. J., Huynh, L., Levin, J., Rinkaekan, P., Kordi, R., Kennedy, D. J. 2017

  Abstract

  To determine if immediate pain response following an injection with local anesthetic and corticosteroid predicts subsequent relief. Prospective observational cohort. An institutional review board-approved prospective study from a single academic medical center. Patients with clinical diagnosis of sacroiliac (SIJ) pain and referred for SIJ injection were enrolled; 1 cc of 2% lidocaine and 1 cc of triamcinolone 40 mg/mL were injected into the SIJ. Pain score on 0-10 numeric rating scale (NRS) during provocation maneuvers was recorded immediately before injection, immediately after injection, and at two and four weeks of follow-up. Oswestry Disability Index (ODI) was also recorded. Various cutoffs were identified to establish positive anesthetic response and successful outcomes at follow-up. These were used to calculated likelihood ratios. Of those with 100% anesthetic response, six of 11 (54.5%, 95% confidence interval [CI]+/-29.4%, +LR 2.6, 95% CI = 1.1-5.9) demonstrated 50% or greater pain relief at follow-up, and four of 11 (36.5%, 95% CI+/-28.4%, +LR 3.00, 95% CI = 1.4-5.1) had 100% relief at two to four weeks. Fourteen of 14 (100%, 95% CI+/-21.5%, -LR 0.0, 95% CI = 0.0-2.1) with an initial negative block failed to achieve 100% relief at follow-up. Patients who fail to achieve initial relief after SIJ injection with anesthetic and steroid are very unlikely to achieve significant pain relief at follow-up; negative likelihood ratios (LR) in this study, based on how success is defined, range between 0 and 0.9. Clinically significant positive likelihood ratios of anesthetic response to SIJ injection are more limited and less robust, but are valuable in predicting 50% relief or 100% relief at two to four weeks.

  View details for DOI 10.1093/pm/pnx104

  View details for PubMedID 28521006

• A Paradigm Shift? Pain medicine (Malden, Mass.) Schneider, B. J., Levin, J., Kennedy, D. J. 2017

  View details for DOI 10.1093/pm/pnx093

  View details for PubMedID 28431156

• TO THE EDITOR. Spine Levi, D., Levin, J. 2016; 41 (6): E379-?

  View details for DOI 10.1097/BRS.0000000000001413

  View details for PubMedID 26720175

• A Narrative Review of Intraarticular Zygapophysial Steroid Injections for Lumbar Zygapophysial Mediated Pain. Current Physical Medicine and Rehabilitation Reports Schneider, B., Levin, J. 2016; 4 (2): 108-116
• Spinal Cord Stimulation for CRPS. Current Physical Medicine and Rehabilitation Reports Drakeley, M., Ho, S., Helm, E., Levin, J., Rosenquist, R. 2016; 4 (2)
• Intradiscal Platelet-Rich Plasma Injection for Chronic Discogenic Low Back Pain: Preliminary Results from a Prospective Trial. Pain medicine (Malden, Mass.) Levi, D. n., Horn, S. n., Tyszko, S. n., Levin, J. n., Hecht-Leavitt, C. n., Walko, E. n. 2016; 17 (6): 1010–22

  Abstract

  Platelet-rich plasma (PRP) has been found to be effective for a variety of musculoskeletal conditions. The treatment of discogenic pain with PRP is under investigation.To assess changes in pain and function in patients with discogenic low back pain after an intradiscal injection of PRP.Prospective trial.Patients were diagnosed with discogenic low back pain by clinical means, imaging, and exclusion of other structures. Provocation discography was used in a minority of the patients. Patients underwent a single treatment of intradiscal injection of PRP at one or multiple levels.Patients were considered a categorical success if they achieved at least 50% improvement in the visual analog score and 30% decrease in the Oswestry Disability Index at 1, 2, and 6 months post-treatment.22 patients underwent intradiscal PRP. Nine patients underwent a single level injection, ten at 2 levels, two at 3 levels, and one at 5 levels. Categorical success rates were as follows: 1 month: 3/22 = 14% (95% CI 0% to 28%), 2 months: 7/22 = 32% (95% CI 12% to 51%), 6 months: 9/19 = 47% (95% CI 25% to 70%).This trial demonstrates encouraging preliminary 6 month findings, using strict categorical success criteria, for intradiscal PRP as a treatment for presumed discogenic low back pain. Randomized placebo controlled trials are needed to further evaluate the efficacy of this treatment.

  View details for DOI 10.1093/pm/pnv053

  View details for PubMedID 26814283

• A Systematic Review of Available Treatments for Discogenic Low Back Pain. Current Physical Medicine and Rehabilitation Reports Lucas, M., Stewart, C., Mattie, R., McCormick, Z., Saltychev, M., Levin, J. 2016; 4 (2): 117-131
• Epidural Steroid Injections are Safe and Effective: Multisociety Letter in Support of the Safety and Effectiveness of Epidural Steroid Injections PAIN MEDICINE Kennedy, D. J., Levin, J., Rosenquist, R., Singh, V., Smith, C., Stojanovic, M. P., Vorobeychik, Y. 2015; 16 (5): 833-838

  Abstract

  In April 2014, the Food and Drug Administration (FDA) issued a Drug Safety Communication requesting that corticosteroid labeling include warnings that injection of corticosteroids into the epidural space of the spine may result in rare but serious adverse events, including loss of vision, stroke, paralysis, and death.The International Spine Intervention Society spearheaded a collaboration of more than a dozen other medical societies in submitting the letter below to the FDA on November 7, 2014. We are publishing the letter to ensure that the readership of Pain Medicine is aware of the multisociety support for the safety and effectiveness of these procedures. A special note of thanks to all of the societies who signed on in support of the message.

  View details for DOI 10.1111/pme.12667

  View details for Web of Science ID 000354742300001

  View details for PubMedID 25586082

• A Systematic Review of the Literature on Caudal, Interlaminar, and Transforaminal Injections From the Last 5 Years. Curr Phys Med Rehabil Rep Mattie, R., McCormick, Z., Yu, S., Kennedy, D., Levin, J. 2015: 159-172

  View details for DOI 10.1007/s40141-015-0087-0

• A Quantitative Study of Intervertebral Disc Morphologic Changes Following Plasma-Mediated Percutaneous Discectomy PAIN MEDICINE Smuck, M., Levin, J., Zemper, E., Ali, A., Kennedy, D. J. 2014; 15 (10): 1695-1703

  Abstract

  To quantitatively evaluate interval magnetic resonance imaging (MRI) changes in disc morphology following plasma-mediated percutaneous discectomy.A retrospective comparison of pretreatment and posttreatment MRIs at a single university spine clinic.From a group of 60 consecutively treated patients, 15 met the study inclusion and exclusion criteria. All had either failed treatment or had other clinical reasons for a posttreatment MRI.Two independent physicians electronically measured disc protrusion size and disc height at the treatment discs and adjacent discs on pre- and posttreatment MRI scans. Additionally, images were compared for gross anatomic changes including disc degeneration by Pfirrman classification, new disc herniations, high intensity zone (HIZ), vertebral endplate changes, post-contrast enhancement, and changes in segmental alignment. Pearson r correlation was used to determine interobserver reliability between the two physicians' MRI measurements. Paired t-tests were calculated for comparisons of pre- and posttreatment MRI measurements, and an ANOVA was performed for comparison of pre- to posttreatment changes in disc height measurements at treatment levels relative to adjacent levels.Correlation was high for measurement of disc height change (r = 0.89; P < 0.0001) and good for anteroposterior protrusion size change (r = 0.51; P = 0.0512). Disc height at treated discs demonstrated a small but statistically significant mean interval reduction of 0.48 mm (P = 0.0018). This remained significant when compared with the adjacent control discs (P < 0.0001). Pretreatment mean disc protrusion size (4.74 mm; range 3.75-6.55 mm) did not differ significantly (P = 0.1145) from posttreatment protrusion size (4.42 mm; range 2.55-7.95 mm). Gross anatomic changes at treatment levels included reduced disc protrusion size (N = 6), enlarged protrusion (N = 3), resolution of HIZ (N = 3), and improvement in endplate signal changes (N = 1). Also, 11/15 posttreatment MRIs included post-contrast images that showed epidural fibrosis (N = 1), rim enhancement (N = 2), and enhancement of the posterior annulus (N = 4).Based on MRI examinations, subtle anatomic changes may occur following plasma-mediated percutaneous discectomy. Further study is required to determine the clinical relevance of these changes.

  View details for DOI 10.1111/pme.12525

  View details for Web of Science ID 000344244800005

• The importance of image guidance during epidural injections: Rates of incorrect needle placement during non-image guided epidural injections J Spine Levin, J., Wetzel, R., Smuck, M. 2012; 1 (2)

  View details for DOI 10.4172/2165-7939.1000113

• Evidence-Based Conviction PM&R Levin, J. H., Smuck, M. 2009; 1 (9): 891-892

  View details for DOI 10.1016/j.pmrj.2009.07.007

  View details for Web of Science ID 000208411900019

• Prospective, double-blind, randomized placebo-controlled trials in interventional spine: what the highest quality literature tells us SPINE JOURNAL Levin, J. H. 2009; 9 (8): 690-703

  Abstract

  The prospective, double-blind, randomized, placebo-controlled study design is essential in the interventional spine literature to truly evaluate whether or not a procedure is effective.This article will critically evaluate the highest quality interventional spine literature with strict interpretation of the results of these trials.Review article.Extensive Medline/Pubmed searches and searches of the large review articles on the major interventional spine topics were performed to find all prospective, double-blind, randomized placebo-controlled trials in the English language interventional spine literature.Fluoroscopically-guided lumbosacral transforaminal epidural corticosteroid injections are effective in the treatment of acute/subacute lumbosacral radicular pain, and in preventing future surgeries. Injection of corticosteroid or Sarapin on the cervical or lumbar medical branch nerves is not effective. When done with proper technique, percutaneous radiofrequency lumbar and cervical medial branch neurotomy are both effective. Intraarticular sacroiliac joint corticosteroid injections are effective in patients with spondyloarthropathy. IDET is modestly effective in the treatment of lumbosacral discogenic pain in carefully selected patients. Percutaneous radio frequency neurotomy of the ramus communicans is effective in the treatment of lumbosacral discogenic pain. No firm conclusions can be drawn about cervical epidural corticosteroid injections, lumbosacral epidural corticosteroid injections for the treatment of chronic radicular pain, cervical or lumbosacral intraarticular zygapophysial joint corticosteroid injections for the treatment of degenerative zygapophysial joint pain, or intradiscal corticosteroid injections.The prospective, double-blind, randomized placebo-controlled trials in the interventional spine literature demonstrate efficacy from several different procedures when properly performed on appropriate patients. Other procedures have been shown to lack efficacy, while inconclusive evidence exists from multiple other interventional spine procedures. Further details are discussed in the text.

  View details for DOI 10.1016/j.spinee.2008.06.447

  View details for Web of Science ID 000268786300013

  View details for PubMedID 18789773

• Rethinking convention. PM & R : the journal of injury, function, and rehabilitation Levin, J. H. 2009; 1 (7): 694-?

  View details for DOI 10.1016/j.pmrj.2009.04.004

  View details for PubMedID 19627966

• Re: Manchikanti L, Singh V, Falco FJ, et al. Cervical medial branch blocks for chronic cervical facet joint pain: a randomized, double-blind, controlled trial with one-year follow-up. Spine 2008;33:1813-20. SPINE Smuck, M., Levin, J. H. 2009; 34 (10): 1116-1116

  View details for DOI 10.1097/BRS.0b013e3181a0a262

  View details for Web of Science ID 000265677900017

  View details for PubMedID 19404184

• Re: Scanlon GC, Moeller-Bertram T, Romanowsky SM, et al. Cervical transforaminal epidural steroid injections: more dangerous than we think? Spine 2007;32:1249-56. Spine Smuck, M. W., Levin, J. H. 2007; 32 (23): 2638-?

  View details for PubMedID 17978668

• Epidural fibrosis following percutaneous disc decompression with coblation technology. Pain physician Smuck, M., Benny, B., Han, A., Levin, J. 2007; 10 (5): 691-696

  Abstract

  Complications reported from percutaneous disc decompression (PDD) include discitis, anaphylaxis (with chemonucleolysis), instability, increased back pain, and reherniation. To the best of our knowledge, there is no report of epidural fibrosis occurring with any of the many types of PDD.To document a case of epidural fibrosis following PDD with coblation technology (Nucleoplasty), a previously unreported complication of this procedure.Case report.Details are presented on a 46-year-old man's history, diagnostic test results, treatments, and progression of his symptoms.Following PDD with coblation technology at L5-S1, the patient noticed improvement in his left lower extremity radicular symptoms and low back pain. He continued to improve over the following week to near complete relief. He resumed his normal activities. Three months post treatment, he experienced a recurrence of his radicular pain with a diminished left Achilles reflex. A subsequent MRI showed improvement of the previous left paracentral protrusion at L5-S1 along with a new contrast enhancing soft tissue mass. This mass, consistent with epidural fibrosis, was located in the left antero-lateral spinal canal and encased the left S1 nerve root. On the patient's next follow-up visit, he reported spontaneous resolution in his symptoms. He had stopped all pain medications and returned to his usual activities.This case is the first reported occurrence of epidural fibrosis following percutaneous lumbar disc decompression.

  View details for PubMedID 17876367

• Radiculopathy from herniation of the nucleus pulposus: 1. Epidemiology, pathophysiology, and natural history J. Back Musculoskeletal Rehabil Levin J, Smuck M 2007; 20 (2,3): 97-101
• Radiculopathy from herniation of the nucleus pulposus: 2. The role of corticosteroids J. Back Musculoskeletal Rehabil Levin J, Smuck M 2007; 20 (2,3): 103-13