Joshua Daniel Rittenberg, MD

All Publications

• Spinal corticosteroid injections are not associated with increased influenza risk. The spine journal : official journal of the North American Spine Society Rittenberg, J. D., Air, M. E., Schmittdiel, J. A., Horton, B. H., Greenlund, L. S., Maus, T. P., Sytsma, T. T. 2022

  Abstract

  Spinal corticosteroid injections (CSI) are often used to treat radicular and axial pain arising from the spine. Systemic corticosteroids are well known to cause immunosuppression, and locally injected spinal CSI are known to have some systemic absorption. However, it is unknown whether spinal CSI increases the risk of systemic viral infections, such as influenza.To determine whether spinal CSI causes an increased risk for influenza infection and whether they reduce the protective effect of vaccination STUDY DESIGN/SETTING: A retrospective cohort study was performed at Kaiser Permanente Northern California, a large healthcare system with a diverse population.Adults (n=60,880) who received a spinal CSI during influenza seasons from 2016 to 2019. A comparison was made with 121,760 case-matched individuals who did not receive a spinal CSI.The primary outcome was odds of influenza diagnosis following spinal CSI compared with case-matched controls. Secondary analysis examined odds of influenza diagnosis based on vaccination status, multiple same-day injections, and epidural versus non-epidural route of injection.The electronic health record and associated research databases were analyzed to identify patients who received a spinal CSI during three consecutive flu seasons, 2016 through 2019. Injections were stratified into epidural versus non-epidural CSI and single injections versus multiple same-day injections. Additionally, the rate of influenza in vaccinated versus non-vaccinated individuals was examined. Inpatient flu diagnosis was used as a proxy for severe disease. After case matching was completed, odds ratios for flu diagnosis were calculated using a logistical regression model.The odds of flu diagnosis following spinal CSI were not increased compared with controls (OR 0.93 [0.87-1.01, 95% Wald CL]). For epidural CSI the OR was 0.91 (0.83-1.00, 95% Wald CL), and non-epidural it was 1.00 (0.89-1.13, 95% Wald CL). There were similar findings for multiple same-day injections and when looking at inpatient flu diagnosis. For vaccinated individuals, the OR for flu following spinal CSI was 0.86 (0.80-0.92, 95% Wald CL), which indicates a protective effect in these patients.Spinal CSI did not increase the odds of subsequently receiving a diagnosis of influenza, regardless of vaccination status, location of injection, single versus multiple same-day injection, or co-morbidity. Vaccination had a protective effect against influenza, and this was not adversely affected by receiving spinal CSI during the flu season.

  View details for DOI 10.1016/j.spinee.2022.02.006

  View details for PubMedID 35181540

• Spinal Region Corticosteroid Injections are not associated with Increased Risk for Influenza. The spine journal : official journal of the North American Spine Society Sytsma, T. T., Rittenberg, J. D., Maus, T. P., Air, M. E., Mauck, W. D., Tiegs-Heiden, C. A., Fischer, K. M., Greenlund, L. S. 2022

  Abstract

  BACKGROUND CONTEXT: Spinal region corticosteroid injections (CSI) are intended to act locally to relieve radicular or axial back pain, however some systemic absorption occurs, potentially placing recipients at risk for immunosuppressive effects of corticosteroids. No previous studies examine whether patients undergoing spinal region CSI are at increased risk for viral infections, particularly influenza-a common viral illness with potentially serious consequences, especially for patients with multimorbidity.PURPOSE: To examine odds of influenza in patients who received spinal region CSI compared to matched controls.STUDY DESIGN: Retrospective cohort study PATIENT SAMPLE: Adults (n = 9196) who received a spinal CSI (epidural, facet, sacroiliac, paravertebral block) during influenza seasons occurring from 2000 to 2020 were 1:1 matched to controls without spinal CSI.OUTCOME MEASURES: The primary outcome was odds of influenza diagnosis in spinal CSI patients compared to matched controls. Predetermined subgroup analyses examined odds of influenza diagnosis based on vaccination status and injection location.METHODS: An institutional database was queried to identify patients that received spinal CSI during influenza season (September 1 to April 30) from 2000 to 2020. Patients were matched by age, sex, and influenza vaccination status to controls without spinal CSI within the specified influenza season. Influenza diagnosis was ascertained using International Classification of Disease (ICD) codes and data was analyzed using multiple logistic regression adjusted for comorbidities associated with increased risk for influenza.RESULTS: 9196 adults (mean age 60.8 years, 60.4% female) received a spinal CSI and were matched to a control. There were no increased odds of influenza for spinal CSI patients as compared to matched controls (OR 1.13, [95% CI, 0.86-1.48]). When subgroups were examined, there was also no increased odds of influenza for spinal CSI patients based on immunization status (unvaccinated or vaccinated) or spinal injection location (epidural or non-epidural).CONCLUSIONS: Spinal region CSI was not associated with increased odds of influenza or reduced vaccine efficacy. This is reassuring given the analgesic and functional restoration benefits of these injections. Assessing risk of viral infection associated with spinal CSI is particularly relevant in the era of the COVID-19 pandemic, and further work is needed to address this issue.KEY WORDS: Steroid, spine, pain, injection, immunosuppression, influenza, vaccine.

  View details for DOI 10.1016/j.spinee.2022.01.014

  View details for PubMedID 35121154

• Adverse events associated with fluoroscopically guided lumbosacral transforaminal epidural steroid injections SPINE JOURNAL Plastaras, C., McCormick, Z. L., Garvan, C., Macron, D., Joshi, A., Chimes, G., Smeal, W., Rittenberg, J., Kennedy, D. J. 2015; 15 (10): 2157-2165

  Abstract

  Although the types and incidence of adverse events (AEs) associated with transforaminal epidural steroid injection (TFESI) have been described, no study has used a systematic standardized questionnaire to solicit AEs from patients to capture an accurate range and incidence of complications.The aim was to systematically identify the types and incidence of AEs associated with TFESI. Additionally, this study evaluated demographic and clinical factors that may predict a higher risk of an AE.This was a retrospective cohort study from a multiphysician academic PM&R clinic.Patients, aged 19 to 89, who underwent a fluoroscopically guided TFESI for lumbosacral radicular pain between 2004 and 2007 were included.The relationship of AEs with gender, age, trainee presence, steroid type, preprocedure visual analog scale (VAS) pain score, systolic blood pressure, fluoroscopy time, and corticosteroid injectate volume was analyzed.Adverse event data were collected using a survey both immediately and at 24 to 72 hours after TFESI. Statistical analysis was performed using the chi-square, Fisher exact, or Wilcoxon rank sum two-sided tests. Logistic regression analysis was also performed. C.P. is the owner of Rehabilitation Institute of Chicago Physiatric Log & Analysis System computer software.In 1,295 consecutive patients undergoing 2,025 TFESI procedures, immediate AEs and delayed AEs occurred after 182 (9.2%) and 305 (20.0%) injections, respectively. The most common immediate AEs were: vasovagal reaction (4.2%) and interrupted procedure from intravascular flow (1.7%). Common delayed AEs included: pain exacerbation (5.0%), injection site soreness (3.9%), headache (3.9%), facial flushing/sweating (1.8%), and insomnia (1.6%). Significant associations were identified between AEs and gender, age, preprocedure VAS, steroid type, and fluoroscopy time. Trainee involvement in the procedure did not impact the complication rate.Fluoroscopically guided lumbosacral TFESI is associated with a similar rate of minor AEs both immediately and 24 to 72 hours after procedure that are typical of other axial corticosteroid injections. Permanent AEs were not found in this sample. The most common AEs associated with TFESI include vasovagal episodes, procedure interruption from intravascular flow, pain exacerbation, injection site soreness, headache, and insomnia.

  View details for DOI 10.1016/j.spinee.2015.05.034

  View details for PubMedID 26065819

• Response to Dr. Candido et?al. Pain medicine Kennedy, D. J., Plastaras, C., Casey, E., Visco, C. J., Rittenberg, J. D., Conrad, B., Sigler, J., Dreyfuss, P. 2014; 15 (11): 1977-1978

  View details for DOI 10.1111/pme.12573

  View details for PubMedID 25338774

• Original Research Articles Comparative Effectiveness of Lumbar Transforaminal Epidural Steroid Injections with Particulate Versus Nonparticulate Corticosteroids for Lumbar Radicular Pain due to Intervertebral Disc Herniation: A Prospective, Randomized, Double-Blind Trial PAIN MEDICINE Kennedy, D. J., Plastaras, C., Casey, E., Visco, C. J., Rittenberg, J. D., Conrad, B., Sigler, J., Dreyfuss, P. 2014; 15 (4): 548-555

  Abstract

  Lumbar transforaminal epidural injections are commonly utilized to treat radicular pain due to intervertebral disc herniation.This study aims to determine if there was a major difference in effectiveness between particulate and nonparticulate corticosteroids for acute radicular pain due to lumbar disc herniation.A multicenter, double blind, prospective, randomized trial on 78 consecutive subjects with acute uni-level disc herniation resulting in unilateral radicular pain. All subjects received a single level transforaminal epidural steroid injection with either dexamethasone or triamcinolone. Repeat injections were allowed as determined by the blinded physician and subjects. Primary outcomes included: number of injections received, surgical rates, and categorical pain scores at 2 weeks, 3 months, and 6 months. Secondary outcomes included mean Oswestry Disability Index.Both triamcinolone and dexamethasone resulted in statically significant improvements in pain and function at 2 weeks, 3 months, and 6 months, without clear differences between groups. The surgical rates were comparable with 14.6% of the dexamethasone group and 18.9% of the triamcinolone group receiving surgery. There was a statistically significant difference in the number of injections received, with 17.1% of the dexamethasone group receiving three injections vs only 2.7% of the triamcinolone group.Transforaminal epidural corticosteroid injections are an effective treatment for acute radicular pain due to disc herniation, and frequently only require 1 or 2 injections for symptomatic relief. Dexamethasone appears to possess reasonably similar effectiveness when compared with triamcinolone. However, the dexamethasone group received slightly more injections than the triamcinolone group to achieve the same outcomes.

  View details for DOI 10.1111/pme.12325

  View details for Web of Science ID 000334111300007

• Vasovagal Rates in Flouroscopically Guided Interventional Procedures: A Study of Over 8,000 Injections PAIN MEDICINE Kennedy, D. J., Schneider, B., Casey, E., Rittenberg, J., Conrad, B., Smuck, M., Plastaras, C. T. 2013; 14 (12): 1854-1859

  Abstract

  To determine the rate of vasovagal (vv) complications in fluoroscopically guided interventional procedures.Retrospective case series analysis of prospectively collected data from March 8, 2004 to January 30, 2009.A single academic medical center.Four thousand one hundred eighty-three subjects undergoing 8,010 consecutive injections.Pearson's chi-square test was used to determine the relationship between categorical variables.A total of 8,010 injections, including epidural steroid injections, radiofrequency nerve ablations, medial branch blocks, hip injections, knee injections, and glenohumeral injections were performed. Overall vv reaction rate was 2.6%, with 0.8% of procedures resulting in early terminated due to vv reaction. Peripheral joint injections had a vv rate of 0.2%, all occurring in hip injections. Transforaminal epidural steroid injections had a vv rate of 3.5%. Diagnostic blocks of the medial branches had the highest rate of vv (5.1%). Other predictors of vv reactions were identified including preprocedure pain score visual analog scale <5 (P = 0.004), male gender (P < 0.001), and age less than 65 years old (P < 0.001).vv reactions have an overall low occurrence rate (2.6%) in interventional procedures ranging from 0% in peripheral knee and shoulder injections to 5.1% in medial branch blocks. Conservative treatment of vv reaction and willingness to terminate procedures resulted in no serious adverse events related to vv reaction in 8,010 procedures.

  View details for DOI 10.1111/pme.12241

  View details for Web of Science ID 000328349400010

  View details for PubMedID 24118835

  View details for PubMedCentralID PMC3887554

• Programmatic Design for Teaching the Introductory Skills and Concepts of Lumbar Spine Procedures to Physiatry Residents A Prospective Multiyear Study AMERICAN JOURNAL OF PHYSICAL MEDICINE & REHABILITATION Visco, C. J., Kennedy, D. J., Chimes, G. P., Rittenberg, J., McLean, J., Dawson, P., Margolis, S., Lento, P., Ihm, J., Sliwa, J., Smeal, W., Sorosky, B., Plastaras, C. 2013; 92 (3): 248-257

  Abstract

  The objective of this study was to determine the effectiveness of a 2-day course teaching the introductory skills and concepts of lumbar spine procedures to physiatry residents.This is a 3-yr prospective study of a 2-day musculoskeletal course teaching the introductory skills and concepts of lumbar spinal procedures to the residents at a large academic physical medicine and rehabilitation program. The residents attending the course took multiple-choice pretests and posttests as well as participated in a procedural skills competency demonstration.Forty-two residents participated. The results were stratified according to the level of training and repetition of the material and revealed gains of medical knowledge at each level of residency training (P < 0.001). The postgraduate year 2 residents seemed to have the greatest overall improvement (P = 0.04). Half of the residents scored lower than 65% on the pretest, and these residents ultimately had the largest posttest gains. Forty (95.2%) residents achieved a grade of pass in the skills-based test. The residents felt that the course was valuable or extremely valuable.The comprehensive 2-day course teaching the skills and concepts of spinal interventions for physiatry residents enhances medical knowledge as an introduction to interventional spine care. Those who benefited the most were the residents who had the greatest deficit of medical knowledge on this topic before the course. This course curriculum does not replace fellowship training or closely monitored mentorship in the performance of spinal procedures.

  View details for DOI 10.1097/PHM.0b013e31826eda9e

  View details for Web of Science ID 000315185400008

  View details for PubMedID 23051759

• Adverse Events Associated With Fluoroscopically Guided Sacroiliac Joint Injections PM&R Plastaras, C. T., Joshi, A. B., Garvan, C., Chimes, G. P., Smeal, W., Rittenberg, J., Lento, P., Stanos, S., Fitzgerald, C. 2012; 4 (7): 473-478

  Abstract

  To describe the type, incidence, and factors that contribute to adverse events associated with fluoroscopically guided intra-articular sacroiliac joint injections (IASIJ).A retrospective cohort study.Tertiary, academic, outpatient physical medicine and rehabilitation interventional spine clinic.English-speaking adults aged 18-90 years who underwent fluoroscopically guided IASIJ injections between March 8, 2004, and April 19, 2007.After IASIJ injections, 3 senior researchers recorded the presence and types of adverse events. The relationship of adverse events with age, gender, fluoroscopy time, vital signs, and trainee presence was analyzed with the Fisher exact or the Wilcoxon rank sum 2-sided tests.The frequency of immediate (during or immediately after the procedure) or delayed (within 24-72 hours after the procedure) adverse events.A total of 162 patients (133 women) underwent 191 procedures. The range of subject age was from 20 to 90 years (15.8 years, standard deviation [SD]). The range (SD) of the preprocedure 11-point Likert Pain Scale was from 1.0 to 10.0 (2.0) and for the postprocedure 11-point Likert Pain Scale was from 0.0 to 9.0 (2.5). Trainees were involved in 57% of the procedures. Reported immediate adverse events were vasovagal reaction (2.1% [n = 4]) and steroid-clogged needle (0.5% [n = 1]). Follow-up data were available for 132 of 191 procedures (69%). There were 32 adverse events reported at a mean follow-up interval of 2 days, of which, the most frequent adverse events were injection-site soreness (12.9% [n = 17]), pain exacerbation (5.3% [n = 7]), and facial flushing and/or sweating (2.3% [n = 3]). Delayed adverse events decreased with older age (P = .0029). The patients who underwent bilateral procedures experienced more delayed adverse events than the patients who underwent unilateral procedures (P = .024).Fluoroscopically guided IASIJ injection is associated with minimal adverse effects. The most common immediate adverse event was vasovagal reaction, and the most common delayed adverse event was injection-site soreness. Younger age is significantly related to reported delayed adverse events.

  View details for DOI 10.1016/j.pmrj.2012.02.001

  View details for Web of Science ID 000306987800002

  View details for PubMedID 22543036

• Cost-effectiveness of the X-STOP (R) Interspinous Spacer for Lumbar Spinal Stenosis A Comparison with Conservative Care and Laminectomy SPINE Skidmore, G., Ackerman, S. J., Bergin, C., Ross, D., Butler, J., Suthar, M., Rittenberg, J. 2011; 36 (5): E345-E356

  View details for DOI 10.1097/BRS.0b013e3181f2ed2f

  View details for Web of Science ID 000287446300009

  View details for PubMedID 21270713

• The Role of Exercise and Alternative Treatments for Low Back Pain PHYSICAL MEDICINE AND REHABILITATION CLINICS OF NORTH AMERICA Carneiro, K. A., Rittenberg, J. D. 2010; 21 (4): 777-+

  Abstract

  The determination of whether a patient should pursue an active or passive treatment program is often made by medical practitioners. Knowledge about all forms of treatment, including complementary and alternative (CAM) treatments, is essential in the treatment of low back pain. Medical practitioner-directed active treatments that have been shown to be effective for the treatment of low back pain include physical therapy-directed exercise programs such as core stabilization and mechanical diagnosis and therapy (MDT). Based on the current literature, it appears that yoga is the most effective nonphysician-directed active treatment approach to nonspecific low back pain when comparing other CAM treatments. Acupuncture is a medical practitioner-directed passive treatment that has been shown to be a good adjunct treatment. More randomized controlled studies are needed to support both CAM treatments and exercise in the treatment of low back pain.

  View details for DOI 10.1016/j.pmr.2010.06.006

  View details for Web of Science ID 000284790100008

  View details for PubMedID 20977960

• Utility of the anesthetic test dose to avoid catastrophic injury during cervical transforaminal epidural injections SPINE JOURNAL Smuck, M., Maxwell, M. D., Kennedy, D., Rittenberg, J. D., Lansberg, M. G., Plastaras, C. T. 2010; 10 (10): 857-864

  Abstract

  Reports of serious complications from cervical transforaminal epidural corticosteroid injections often consider accidental intra-arterial injection the most likely mechanism of injury. As a result, many physicians have instituted methods to prevent intravascular injections. Routine use of the anesthetic test dose is one such method. The utility of the anesthetic test dose in this function has not been characterized in the current literature.The aim of this study was to determine the utility of injecting an anesthetic test dose before cervical transforaminal epidural corticosteroid injection and estimate the rate of false-negative intravascular contrast injection using live fluoroscopy and digital subtraction angiography (DSA).Two-center retrospective study.A consecutive cohort of men and women, ages of 23 to 83, who underwent cervical transforaminal epidural injection and received the anesthetic test dose after contrast injection was negative for vascular uptake, observed using live fluoroscopy or DSA.Response to the anesthetic test dose was documented in each procedure note and recorded as either positive or negative.Records of three physiatrists at two academic spine centers (Center A and Center B) were reviewed to identify all patients who received a cervical transforaminal epidural injection during the preceding 5 years, resulting in a cohort of consecutively treated patients at each center. Each patient record was reviewed for demographics, indication for injection, procedure level and side, needle gauge, use of DSA, volume and type of anesthetic test dose used, and result of test dose injection. The test dose was considered positive if the following occurred: agitation or other sudden central nervous system change; gross motor deficits and/or paresthesias in the trunk, legs, or contralateral arm; systemic symptoms of anesthetic toxicity including cardiac arrhythmia, perioral numbness, metallic taste, dizziness, and/or ringing in the ear. For analysis, injections were separated into groups to compare results at Center A to Center B and to compare injections that used DSA to those that did not. The incidence of a positive response was calculated as a percentage from the total number of injections in the group. Differences between groups were analyzed for statistical significance using the Fisher exact test.Six hundred seventy-eight injections were included. Of these, 349 were performed at Center A with test doses given after contrast injection under live fluoroscopy. The remaining 329 were performed at Center B, 183 also using live fluoroscopy, and 146 using DSA. The overall incidence of a positive anesthetic test dose was 0.59% (4/678). There was no significant difference between the incidence at each of the two centers (0.86% [3/349] vs. 0.30% [1/329]; p=.63). The overall incidence after live fluoroscopy was 0.75% (4/532) and after DSA was 0% (0/146), but this difference was not statistically significant (p=.58). Positive symptoms elicited by test dose administration included midneck and contralateral arm pain, metallic taste, dizziness, tachycardia, full body paresthesias, auditory changes, slurred speech, and motor ataxia. In all four cases with a positive response, the procedure was immediately terminated, symptoms resolved, and no lasting complications were observed.The routine use of an anesthetic test dose appears to be safe and capable of detecting potentially dangerous intravascular injections undetected by conventional techniques. Positive responses occur in a small portion of those who receive the test dose injection. Further studies are required to determine the optimal dose and concentration of anesthetic to be used and the time required for observation after test dose administration.

  View details for DOI 10.1016/j.spinee.2010.07.003

  View details for Web of Science ID 000283190400002

  View details for PubMedID 20692210

• Inadvertent Intradiscal Contrast Flow During Lumbar Transforaminal Epidural Steroid Injections: A Case Series Examining the Prevalence of Intradiscal Injection as well as Potential Associated Factors and Adverse Events PAIN MEDICINE Plastaras, C. T., Casey, E., Goodman, B. S., Chou, L., Roth, D., Rittenberg, J. 2010; 11 (12): 1765-1773

  Abstract

  The primary aim was to evaluate the prevalence of inadvertent intradiscal injection during fluoroscopically guided contrast-enhanced lumbar transforaminal epidural steroid injections. The secondary aim was to determine if there are any risk factors for or adverse events as a result of inadvertent intradiscal contrast injection.The study was a retrospective case series.The study was set in three outpatient spine care centers.A search was conducted in a database of spinal injection procedures from July 2000-May 2008. Fifteen cases of inadvertent intradiscal contrast flow were identified. These cases were matched with one control case with the same age, gender, level, and side of injection.The prevalence of intradiscal contrast flow with lumbar transforaminal epidural steroid injection was calculated. Chart review of the cases and controls was performed. An independent, blinded examiner evaluated needle tip placement.Frequency of intradiscal contrast flow during lumbar transforaminal epidural steroid injections and the relationship between the occurrence of intradiscal contrast flow with potential risk factors.The prevalence of inadvertent intradiscal injection during lumbar transforaminal epidural steroid injections was 0.17%. All of the patients received prophylactic antibiotics after inadvertent disk injection, and there were no infectious or other complications identified.Intradiscal contrast injection is an infrequently reported event during lumbar transforaminal epidural steroid injections. Our data support that the prevalence is very low and there might be an association with ipsilateral foraminal stenosis. Although there is potential for significant adverse complications with intradiscal injection, our data set did not show serious sequelae.

  View details for DOI 10.1111/j.1526-4637.2010.00943.x

  View details for Web of Science ID 000285066100006

  View details for PubMedID 20807341

• The Rate of Detection of Intravascular Injection in Cervical Transforaminal Epidural Steroid Injections With and Without Digital Subtraction Angiography PM&R McLean, J. P., Sigler, J. D., Plastaras, C. T., Garvan, C., Riffenberg, J. D. 2009; 1 (7): 636-642

  Abstract

  To determine whether digital subtraction angiography (DSA) combined with real-time fluoroscopic imaging improves the detection rate of intravascular injection during cervical transforaminal epidural steroid injections (CTFESIs).Retrospective analysis.Outpatient surgery center.A total of 134 subjects with cervical radicular pain who had CTFESIs performed by a single physician between June 9, 2004, and April 23, 2007.One hundred seventy-seven CTFESIs performed at one or more cervical spinal levels either unilaterally or bilaterally. Procedures performed before September 12, 2005, used fluoroscopic guidance with contrast injection and live imaging to identify intravascular injection. All procedures performed after September 12, 2005, also included DSA.Intravascular injection detected during CTFESIs with and without DSA.Intravascular injection was detected in 17.9% of CTFESIs performed without DSA. By adding DSA technology to the real-time fluoroscopic imaging procedure, the detection of vascular injection nearly doubled to 32.8%, which was statistically significant (P = .0471).The use of DSA improves the detection rate of intravascular injection during CTFESIs.

  View details for DOI 10.1016/j.pmrj.2009.03.017

  View details for Web of Science ID 000208411700006

  View details for PubMedID 19627957

• Efficacy of Lumbosacral Transforaminal Epidural Steroid Injections: A Systematic Review PM&R Roberts, S. T., Willick, S. E., Rho, M. E., Rittenberg, J. D. 2009; 1 (7): 657-668

  Abstract

  To critically review the best available studies evaluating the efficacy of lumbosacral transforaminal epidural steroid injections (TFESIs) in the treatment of radicular pain.MEDLINE, EMBASE, and the Cochrane database were searched for the period between 1950 and May 2008. Search terms included epidural steroid injection (ESI), transforaminal ESI, foraminal ESI, selective nerve root block, nerve root injection (NRI), selective NRI, periradicular infiltration, and periradicular injection. Randomized controlled trials (RCTs), published in English, which evaluated the efficacy of fluoroscopically guided TFESIs were reviewed.Studies were analyzed with a quality checklist modeled after the 2001 CONSORT Statement: Revised Recommendations for Improving the Quality of Reports of Parallel-Group Randomized Trials. Nine studies were found to include a majority of these items.Data included study design, inclusion criteria, symptom duration, randomization protocol, blinding protocol, intervention, control, outcomes, follow-up, dropout, statistical analysis, and conclusions.Each article was assigned a level of evidence: I (high-quality RCT) or II (RCT with <80% follow-up, no blinding or improper randomization). Studies were divided according to control, and overall evidence was graded as A (good), B (fair), C (conflicting/poor quality), or I (insufficient).There is fair evidence supporting TFESIs as superior to placebo for treating radicular symptoms. There is good evidence that TFESIs should be used as a surgery-sparing intervention, and that TFESIs are superior to interlaminar ESIs (ILESIs) and caudal ESIs for radicular pain. In patients with subacute or chronic radicular symptoms, there is good evidence that a single TFESI has similar efficacy as a single transforaminal injection of bupivacaine or saline. Future studies should address the ideal number of injections. While more placebo-controlled trials are needed to conclusively define the role of TFESIs, current studies support their use in the treatment of lumbosacral radicular pain.

  View details for DOI 10.1016/j.pmrj.2009.04.008

  View details for Web of Science ID 000208411700008

  View details for PubMedID 19627959

• Panel Discussion AMERICAN JOURNAL OF THERAPEUTICS McCarberg, B., Barkin, R. L., Fish, L., Kulich, R. J., Kuritzky, L., Nicholson, B. D., Rittenberg, J., Viscusi, E., Weaver, A. L. 2008; 15: S24-S27

  View details for DOI 10.1097/MJT.0b013e31818be683

  View details for Web of Science ID 000261308500006

  View details for PubMedID 19127126

• Comprehensive functional evaluation of the injured runner. Physical medicine and rehabilitation clinics of North America Plastaras, C. T., Rittenberg, J. D., Rittenberg, K. E., Press, J., Akuthota, V. 2005; 16 (3): 623-49

  Abstract

  In most cases, a detailed history provides the information that is necessary for the clinician to diagnose the injured runner correctly; however, to treat the injury and guide a successful rehabilitation program, the physical examination must go beyond the standard regional musculoskeletal examination. The victims (tissue injury) and the culprits (biomechanical deficits) must be identified to facilitate treatment (Table 3). Gait and other dynamic assessments help to reveal underlying deficits in function that may have contributed to injury. In short, the entire functional kinetic chain must be considered and weak links identified.

  View details for DOI 10.1016/j.pmr.2005.02.005

  View details for PubMedID 16005397

• The practical management of Achilles tendinopathy CLINICAL JOURNAL OF SPORT MEDICINE Sorosky, B., Press, J., Plastaras, C., Rittenberg, J. 2004; 14 (1): 40-44

  View details for DOI 10.1097/00042752-200401000-00007

  View details for Web of Science ID 000230326800007

  View details for PubMedID 14712165

• Worsening myelopathy masked by peripheral nerve disorders JOURNAL OF SPINAL CORD MEDICINE Rittenberg, J. D., Burns, S. P., Little, J. W. 2004; 27 (1): 72-77

  Abstract

  Peripheral nerve disorders--whether due to peripheral nerve entrapment or to polyneuropathy--can alter the signs of myelopathy, masking both the sensory loss and distal hyperreflexia. Diagnosis of worsening myelopathy may be missed when there is a coexisting peripheral nerve disorder.This study is a case description and analysis of 3 consecutive cases identified over 2 years.Three cases were identified in which the diagnosis of worsening myelopathy was missed and treatment was delayed because neurologic decline was attributed to a coexisting peripheral nerve disorder. This report describes 2 cases of posttraumatic syringomyelia masked by superimposed peripheral nerve entrapments and 1 case of cervical myelopathy due to cervical spinal stenosis from ossification of the posterior longitudinal ligament masked by diabetic polyneuropathy.It is important to continually question whether the working diagnosis of peripheral nerve disorder explains the clinical findings, given neurologic decline; or whether a superimposed worsening myelopathy may coexist. Early diagnosis of worsening myelopathy is important, because prompt treatment of syringomyelia and myelopathy due to cervical spinal stenosis may yield better outcomes. Early diagnosis is aided by (a) considering alternative and multiple diagnoses, (b) assessing spinothalamic as well as posterior column sensation and assessing these sensory modalities for proximal as well as distal limbs, (c) assessing tendon hyperreflexia of proximal as well as distal limb muscles, and (d) utilizing electrodiagnostic tests that can identify myelopathy.

  View details for DOI 10.1080/10790268.2004.11753733

  View details for Web of Science ID 000189312200011

  View details for PubMedID 15156940

• Functional rehabilitation for degenerative lumbar spinal stenosis. Physical medicine and rehabilitation clinics of North America Rittenberg, J. D., Ross, A. E. 2003; 14 (1): 111-20

  Abstract

  Nonoperative treatment for lumbar spinal stenosis must address anatomic and biomechanical factors. The entire functional kinetic chain and patient specific goals must be considered. In addition to passive modalities, manual therapy, and patient education, an active program consisting of flexion-based lumbar stabilization exercises, hip mobilization, proprioceptive training, and general conditioning should be initiated. More studies are needed to establish the benefit of a comprehensive, multifaceted treatment approach and to prove its clear benefit over the natural history of lumbar spinal stenosis.

  View details for DOI 10.1016/S1047-9651(02)00082-7

  View details for PubMedID 12622486

• Radiation exposure of the spinal interventionalist performing fluoroscopically guided lumbar transforaminal epidural steroid injections ARCHIVES OF PHYSICAL MEDICINE AND REHABILITATION Botwin, K. P., Thomas, S., Gruber, R. D., Torres, F. M., Bouchlas, C. C., Rittenberg, J. J., Rao, S. 2002; 83 (5): 697-701

  Abstract

  To evaluate radiation exposure to spinal interventionalists while performing transforaminal epidural steroid injections (TFESIs).Prospective study.Multidisciplinary spine center.One hundred consecutive patients with either herniated nucleus pulposus (HNP) or lumbar spinal stenosis (LSS).Fluroscopically guided lumbar TFESIs.Radiation exposure was monitored by radiography technologists who allocated 4 dosimetry badges to all spinal interventionalists performing fluroscopically guided lumbar TFESIs on patients being treated for radicular pain. Badges were placed on the ring finger, glasses, and the inside and outside of the lead apron worn by the interventionalists. The radiography technologists also wore marked badges outside their lead aprons. One control badge was placed 67in away from the fluoroscopy table and a second badge was placed in a desk more than 500ft away from the procedure to monitor ambient radiation.The average fluoroscopy time per procedure was 15.16 seconds. The average exposure per procedure was 0.7mrem at the ring badge, 0.4mrem at the glasses badge, and 0.3mrem at the outside apron badge. No radiation was detectable at the inside apron or at the outside room control badge. The cumulative exposure to the interventionalists from all 100 procedures was 70mrem at the ring badge, 40mrem at the glasses badge, and 30mrem at the outside apron badge. The radiography technologists' average exposure during these procedures was below the limit of detectablility. Radiation time under fluoroscopy ranged from 5 to 38 seconds. The interventionalist's exposure to radiation was significantly greater during procedures conducted on patients with LSS then during procedures on patients with HNP.Adhering to a radiation safety program that includes maximizing the distance the spinal interventionalist is from the radiation source, decreasing exposure time, and proper shielding is essential when performing fluoroscopically guided lumbar TFESIs. Our study shows that exposure to radiation of the spinal interventionalist performing fluoroscopically guided lumbar TFESIs was well within safety limits when proper techniques were followed.

  View details for DOI 10.1053/apmr.2002.32439

  View details for Web of Science ID 000175494000016

  View details for PubMedID 11994810

• Complications of fluoroscopically guided caudal epidural injections AMERICAN JOURNAL OF PHYSICAL MEDICINE & REHABILITATION Botwin, K. P., Gruber, R. D., Bouchlas, C. G., Torres-Ramos, F. M., Hanna, A., Rittenberg, J., Thomas, S. A. 2001; 80 (6): 416-424

  Abstract

  To assess the incidence of complications of fluoroscopically guided caudal epidural injections.A retrospective cohort design study in which chart review was performed on patients, who presented with radiculopathy and received fluoroscopically guided caudal epidural steroid injections. All injections were performed consecutively over a 12-mo period. An independent observer reviewed medical charts, which included a 24-hr post procedure telephone call by an ambulatory surgery center nurse, who asked a standardized questionnaire about complications after the injections. Physician follow-up office notes 1 to 3 wk after injection along with epidurograms were reviewed.The charts of 139 patients, who received 257 injections, were reviewed. Complications per injection included 12 episodes of insomnia the night of the injection (4.7%), 9 transient nonpositional headaches that resolved within 24 hr (3.5%), 8 increased back pain (3.1%), 6 facial flushing (2.3%), 2 vasovagal reactions (0.8%), 2 episodes of nausea (0.8%), and 1 increased leg pain (0.4%). No dural punctures occurred.No major complications occurred. The incidence of minor complications was 15.6% per injection. All reactions resolved without morbidity and no patient required hospitalization.

  View details for DOI 10.1097/00002060-200106000-00005

  View details for Web of Science ID 000169036100004

  View details for PubMedID 11399002