Dr. Rittenberg is a board-certified, fellowship-trained physiatrist specializing in rehabilitative and interventional spine care. He is a clinical associate professor in the Department of Orthopaedic Surgery, Division of Physical Medicine & Rehabilitation.
In his clinical practice, Dr. Rittenberg provides expert care for painful spine disorders. He excels at interventional pain management and has extensive experience in a variety of spinal disorders, including sports-related spine injuries
Prior to joining Stanford, he was co-chair of the Physical Medicine and Rehabilitation Department for Kaiser Northern California. Additionally, he spent 10 years at the Rehabilitation Institute of Chicago, where he served as Medical Director of Musculoskeletal and Spine Procedures at the Spine and Sports Rehabilitation Center. He was a consultant in the Northwestern Medical Faculty Foundation Department of Orthopedic Surgery and an Associate Professor in the Department of Physical Medicine and Rehabilitation at Northwestern University Feinberg School of Medicine.
Dr. Rittenberg excels at the diagnosis and treatment of disorders involving the spine. He delivers state-of-the-art treatment for pain, emphasizing non-operative and minimally invasive approaches.
For each patient, he prepares a personalized plan of care designed to be both comprehensive and compassionate. In every case, his goals are to relieve symptoms and enable the best possible quality of life.
Dr. Rittenberg lectures nationally and internationally, has chaired numerous courses, and has published original research, review articles, and book chapters in the areas of interventional and rehabilitative spine care.
He has volunteered and held leadership positions in the American Academy of Physical Medicine and Rehabilitation, the North American Spine Society, and the Spine Intervention Society. He is the current Vice President of the Spine Intervention Society(SIS).
Dr. Rittenberg has earned honors and recognition for his achievements. They include being named to the Healthgrades Honor Roll and recognized as a regional top doctor by Castle Connolly, the research and information resource for health care consumers.
- Physical Medicine and Rehab
- Interventional Spine
- Spine Rehabilitation
Clinical Associate Professor, Orthopaedic Surgery
Board Certification: American Board of Physical Medicine and Rehab, Pain Medicine (2004)
Fellowship: Florida Spine Institute (2000) FL
Residency: University of Washington PMandR Residency Program (1999) WA
Internship: St. Vincent's Hospital (1996) NY
Medical Education: New York Medical College Registrar (1995) NY
Spinal corticosteroid injections are not associated with increased influenza risk.
The spine journal : official journal of the North American Spine Society
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
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
2015; 15 (10): 2157-2165
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 2014; 15 (11): 1977-1978
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
2014; 15 (4): 548-555
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
2013; 14 (12): 1854-1859
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
2013; 92 (3): 248-257
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
Utility of the anesthetic test dose to avoid catastrophic injury during cervical transforaminal epidural injections
2010; 10 (10): 857-864
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