Matthew Smuck, MD

All Publications

• A cost-effectiveness analysis of intraosseous basivertebral nerve ablation for the treatment of chronic low back pain. The spine journal : official journal of the North American Spine Society Smuck, M., McCormick, Z. L., Gilligan, C., Hailey, M. K., Quinn, M. L., Bentley, A., Metcalfe, K., Bradbury, B., Lukes, D. J., Taylor, R. S. 2024

  Abstract

  Randomized trials have demonstrated the superiority of intraosseous basivertebral nerve ablation (BVNA) compared with sham and standard care in terms of improvements in pain, disability, and health-related quality of life in patients with vertebrogenic chronic low back pain (cLBP).To assess the cost effectiveness of BVNA in patients with vertebrogenic cLBP compared to standard care alone.A model-based economic analysis.Base case analysis used INTRACEPT, a randomized trial comparing BVNA with standard care in 140 patients with vertebrogenic cLBP, recruited from 23 sites across the United States, with a follow-up, up to 5 years. Scenario analyses compared data from the Surgical Multi-center Assessment of Radiofrequency Ablation for the Treatment of Vertebrogenic Back Pain (SMART) randomized trial against a sham control, and a single-arm study.Costs and quality-adjusted life years (QALYs) were calculated to determine the incremental cost-effectiveness ratio (ICER).A cost-effectiveness model was built in Microsoft Excel® to evaluate the costs and health outcomes of patients undergoing BVNA using the Intracept Procedure (Relievant Medsystems) to treat vertebrogenic cLBP from a US payor perspective. Alternative scenario sensitivity analyses and probabilistic sensitivity analyses were conducted to assess the robustness of the model results. QALYs were discounted at 3.0% per year.Base case analysis showed that BVNA relative to standard care alone was a cost-effective strategy for the management of patients with vertebrogenic cLBP, with an ICER of US$11,376 per QALY at a 5-year time horizon from introduction of the procedure. Modeling demonstrated a >99% probability that this was cost effective in the US, based on a willingness-to-pay threshold of US$100,000 to US$150,000. Various sensitivity and scenario analyses produced ICERs that all remained below this threshold.BVNA with the Intracept Procedure offers patients with vertebrogenic cLBP, clinicians, and healthcare systems a cost-effective treatment compared to standard care alone.

  View details for DOI 10.1016/j.spinee.2024.09.016

  View details for PubMedID 39332685

• Insole Pressure Sensors to Assess Post-Stroke Gait. Annals of rehabilitation medicine Nam, H. S., Clancy, C., Smuck, M., Lansberg, M. G. 2024

  Abstract

  Objective: To confirm that the simplified insole does not affect the gait speed and to identify objective sensor-based gait parameters that correlate strongly with existing clinical gait assessment scales.Methods: Ten participants with gait impairment due to hemiplegic stroke were enrolled in this study. Pairs of insoles with four pressure sensors on each side were manufactured and placed in each shoe. Data were extracted during the 10-Meter Walk Test. Several sensor-derived parameters (for example stance time, heel_on-to-toe_peak time, and toe_peak pressure) were calculated and correlated with gait speed and lower extremity Fugl-Meyer (F-M) score.Results: The insole pressure sensor did not affect gait, as indicated by a strong correlation (rho=0.988) and high agreement (ICC=0.924) between the gait speeds with and without the insole. The parameters that correlated most strongly with highest beta coefficients against the clinical measures were stance time of the non-hemiplegic leg (beta=-0.87 with F-M and beta=-0.95 with gait speed) and heel_on-to-toe_peak time of the non-hemiplegic leg (beta=-0.86 with F-M and -0.94 with gait speed).Conclusion: Stance time of the non-hemiparetic leg correlates most strongly with clinical measures and can be assessed using a non-obtrusive insole pressure sensor that does not affect gait function. These results suggest that an insole pressure sensor, which is applicable in a home environment, may be useful as a clinical endpoint in post-stroke gait therapy trials.

  View details for DOI 10.5535/arm.23064

  View details for PubMedID 38200402

• Low Back Pain-related Healthcare Utilization following Intraosseous Basivertebral Nerve Radiofrequency Ablation: A Pooled Analysis from Three Prospective Clinical Trials. Pain medicine (Malden, Mass.) McCormick, Z. L., Curtis, T., Cooper, A., Wheatley, M., Smuck, M. 2023

  Abstract

  The effectiveness and safety of intraosseous basivertebral nerve ablation (BVNA) for treating vertebrogenic pain is established, but low back pain-related healthcare utilization (LBPr-HU) following BVNA continues to be defined.LBPr-HU data were pooled from three prospective studies. LBPr-HU categories of interest included non-invasive conservative care, opioid utilization, lumbosacral spinal injection (LSI), lumbosacral radiofrequency ablation (LRFA), and lumbosacral spinal surgery. Pre- and post-BVNA LBPr-HU were compared at both one- and five-years using McNemar's test for proportions and paired t-tests for means.Two hundred forty-seven patients received BVNA and had one-year follow-up; 205 had long-term follow-up (mean of 5.3 ± 1.33 years). Twenty-seven percent fewer participants initiated conservative care in the year post-BVNA compared to the year preceding BVNA (p < 0.001; 95%CI 19.8-34.5). Of 77/247 participants taking opioids at baseline, 40.3% and 61.7% fewer were taking them at one-year and 5.3 ± 1.33 years post-BVNA, respectively (p < 0.001). Of participants receiving LSIs in the year preceding BVNA, 81.2% fewer received LSI(s) in the year post-BVNA (p < 0.001; 95%CI 70.7-90.7); a 76.4% reduction in LSIs was maintained through a mean of 5.3 ± 1.33 years post-BVNA. LRFA rates were 1.6% at one-year post-BVNA and 8.3% at 5.3 ± 1.33 years post-BVNA. Lumbar fusion surgery was 0.8% at one-year post-BVNA and 6.5% at 5.3 ± 1.33 years post-BVNA.In this aggregate analysis of patients with vertebrogenic pain, utilization of conservative care, opioids, LSIs, and LRFA were substantially reduced through five years post-BVNA compared to baseline. Lumbar fusion rates were less than half the published value at five years in similar populations.

  View details for DOI 10.1093/pm/pnad114

  View details for PubMedID 37643639

• 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

• LONGITUDINAL ANALYSIS BETWEEN THE PROGRESSION OF KNEE OSTEOARTHRITIS AND PHYSICAL ACTIVITY: DATA FROM THE OSTEOARTHRITIS INITIATIVE Kushioka, J., Sun, R., Smuck, M. ELSEVIER SCI LTD. 2023: S159

  View details for Web of Science ID 001013148000192

• Self-reported physical function is strongly related to pain behavior and pain interference and weakly related to physical capacity in people with chronic low back pain. Musculoskeletal science & practice Karayannis, N. V., Smuck, M., Law, C., Mackey, S. C., Gross, J. J., Darnall, B. D., Hush, J. 2023: 102721

  Abstract

  BACKGROUND: Inclusion of self-reported and capacity-based measures may help to further elucidate the interactive link between how people think and move.OBJECTIVE: To characterize the relationship between self-reported factors of physical function and pain with objective physical capacity measures.DESIGN: Cross-sectional study of 328 adults with chronic low back pain (CLBP).METHOD: Spearman correlations assessed the relationship between pairs of measures. Multiple linear regression models assessed the association between self-reported measures of physical function and the grouping of physical capacity measures. Self-reported measures included Roland Morris Disability Questionnaire (RMDQ), PROMIS Physical Function, Pain Behavior, and Pain Interference; Fear-Avoidance Beliefs Questionnaire (FABQ), Pain Catastrophizing Scale (PCS), and Chronic Pain Acceptance Questionnaire (CPAQ). Capacity measures included walking speed and endurance, lower extremity functional strength, lumbopelvic range of motion, and trunk endurance.RESULTS: PROMIS Physical Function was directly and weakly correlated with walking speed (rho=0.26, 2-min walk) and inversely and weakly correlated with lower extremity strength (rho=-0.29, 5x sit-to-stand). RMDQ was not correlated with any of the capacity-based measures. PROMIS Physical Function was inversely and moderately correlated with Pain Interference (rho=-0.48) and Pain Behavior (rho=-0.43), PCS (rho=-0.36), and FABQ (rho=-0.31). The RMDQ was strongly correlated with PROMIS Physical Function (rho=-0.56), Pain Behavior (rho=0.51) and Pain Interference (rho=0.49); and moderately correlated with PCS (rho=0.37) and FABQ (rho=0.33). PROMIS Physical Function and RMDQ were not correlated with CPAQ. Lower scores on PROMIS Physical Function were weakly associated with lower measures of lower extremity strength (-0.30, 95% CI: -0.51 to -0.09, p=0.005). Higher scores on RMDQ were also weakly associated with lower measures of lower extremity strength (0.26, 95% CI: 0.11 to 0.41, p=0.001).CONCLUSIONS: A strong association emerged between self-reported limitations in physical function, pain behavior, and pain interference. A weak association emerged between self-reported physical function and lower extremity strength.

  View details for DOI 10.1016/j.msksp.2023.102721

  View details for PubMedID 36759316

• A Comparison of Wrist- Versus Hip-Worn ActiGraph Sensors for Assessing Physical Activity in Adults: A Systematic Review JOURNAL FOR THE MEASUREMENT OF PHYSICAL BEHAVIOUR Gall, N., Sun, R., Smuck, M. 2022; 5 (4): 252-262

  View details for DOI 10.1123/jmpb.2021-0045

  View details for Web of Science ID 001289025800006

• Gait Variability to Phenotype Common Orthopedic Gait Impairments Using Wearable Sensors. Sensors (Basel, Switzerland) Kushioka, J., Sun, R., Zhang, W., Muaremi, A., Leutheuser, H., Odonkor, C. A., Smuck, M. 2022; 22 (23)

  Abstract

  Mobility impairments are a common symptom of age-related degenerative diseases. Gait features can discriminate those with mobility disorders from healthy individuals, yet phenotyping specific pathologies remains challenging. This study aims to identify if gait parameters derived from two foot-mounted inertial measurement units (IMU) during the 6 min walk test (6MWT) can phenotype mobility impairment from different pathologies (Lumbar spinal stenosis (LSS)-neurogenic diseases, and knee osteoarthritis (KOA)-structural joint disease). Bilateral foot-mounted IMU data during the 6MWT were collected from patients with LSS and KOA and matched healthy controls (N = 30, 10 for each group). Eleven gait parameters representing four domains (pace, rhythm, asymmetry, variability) were derived for each minute of the 6MWT. In the entire 6MWT, gait parameters in all four domains distinguished between controls and both disease groups; however, the disease groups demonstrated no statistical differences, with a trend toward higher stride length variability in the LSS group (p = 0.057). Additional minute-by-minute comparisons identified stride length variability as a statistically significant marker between disease groups during the middle portion of 6WMT (3rd min: p ≤ 0.05; 4th min: p = 0.06). These findings demonstrate that gait variability measures are a potential biomarker to phenotype mobility impairment from different pathologies. Increased gait variability indicates loss of gait rhythmicity, a common feature in neurologic impairment of locomotor control, thus reflecting the underlying mechanism for the gait impairment in LSS. Findings from this work also identify the middle portion of the 6MWT as a potential window to detect subtle gait differences between individuals with different origins of gait impairment.

  View details for DOI 10.3390/s22239301

  View details for PubMedID 36502003

  View details for PubMedCentralID PMC9739785

• Biomechanical Phenotyping of Chronic Low Back Pain: Protocol for BACPAC. Pain medicine (Malden, Mass.) Adam Quirk, D., Johnson, M. E., Anderson, D. E., Smuck, M., Sun, R., Matthew, R., Bailey, J., Marras, W. S., Bell, K. M., Darwin, J., Bowden, A. E. 2022

  Abstract

  OBJECTIVE: Biomechanics represents the common final output through which all biopsychosocial constructs of back pain must pass, making it a rich target for phenotyping. To exploit this feature, several sites within the NIH Back Pain Consortium (BACPAC) have developed biomechanics measurement and phenotyping tools. The overall aims of this paper were to: 1) provide a narrative review of biomechanics as a phenotyping tool; 2) describe the diverse array of tools and outcome measures that exist within BACPAC; and 3) highlight how leveraging these technologies with the other data collected within BACPAC may elucidate the relationship between biomechanics and other metrics used to characterize low back pain (LBP).METHODS: The narrative review highlights how biomechanical outcomes can discriminate between those with and without LBP, as well as the severity of LBP. It also addresses how biomechanical outcomes track with functional improvements in LBP. Additionally, we present the clinical use case for biomechanical outcome measures that can be met via emerging technologies.RESULTS: To answer the need of measuring biomechanical performance our results section describes the spectrum of technologies that have been developed and are being used within BACPAC.CONCLUSION: and future directions: The outcome measures collected by these technologies will be an integral part of longitudinal and cross-sectional studies conducted in BACPAC. Linking these measures with other biopsychosocial data collected within BACPAC increases our potential to use biomechanics as a tool for understanding the mechanisms of LBP, phenotyping unique LBP subgroups, and matching these individuals with an appropriate treatment paradigm.

  View details for DOI 10.1093/pm/pnac163

  View details for PubMedID 36315101

• Evaluation of Motion Segment Size as a New Sensor-based Functional Outcome Measure in Stroke Rehabilitation. The Journal of international medical research Nam, H. S., Lee, W. H., Seo, H. G., Smuck, M. W., Kim, S. 2022; 50 (9): 3000605221122750

  Abstract

  OBJECTIVE: To evaluate a novel parameter, motion segment size (MSS), in stroke patients with upper limb impairment and validate its clinical applicability by correlating results with a standard clinical task-based functional evaluation tool.METHODS: In this cross-sectional study, patients with hemiplegia and healthy controls equipped with multiple inertial measurement unit (IMU) sensors performed Action Research Arm Test (ARAT) and activities of daily living (ADL) tasks. Acceleration of the wrist and Euler angles of each upper limb segment were measured. The average and maximum MSS, accumulated motion, total performance time, and average motion speed (AMS) were extracted for analysis.RESULTS: Data from nine patients and 10 controls showed that the average MSS of forearm supination/pronation and elbow flexion/extension during full ARAT tasks showed a significant difference between patients and controls and a significant correlation with ARAT scores.CONCLUSIONS: We suggest that MSS may provide clinically relevant information regarding upper limb functional status in stroke patients.

  View details for DOI 10.1177/03000605221122750

  View details for PubMedID 36129970

• 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

• Magnetic Resonance Imaging Characteristics Associated with Treatment Success from Basivertebral Nerve Ablation: An Aggregated Cohort Study of Multicenter Prospective Clinical Trials Data. Pain medicine (Malden, Mass.) McCormick, Z. L., Conger, A., Smuck, M., Lotz, J. C., Hirsch, J. A., Hickman, C., Harper, K., Burnham, T. R. 2022; 23 (Supplement_2): S34-S49

  Abstract

  OBJECTIVE: Investigate associations between endplate and motion segment magnetic resonance imaging (MRI) characteristics and treatment outcomes following basivertebral nerve radiofrequency ablation (BVN RFA) in patients with clinically suspected vertebral endplate pain (VEP).DESIGN: Aggregated cohort study of 296 participants treated with BVN RFA from three prospective clinical trials.METHODS: Baseline MRI characteristics were analyzed using stepwise logistic regression to identify factors associated with treatment success. Predictive models used three definitions of treatment success: (1) ≥50% low back pain (LBP) visual analog scale (VAS), (2) ≥15-point Oswestry Disability Index (ODI), and (3) ≥50% VAS or ≥15-point ODI improvements at 3-months post-BVN RFA.RESULTS: The presence of lumbar facet joint fluid (odds ratio [OR] 0.586) reduced the odds of BVN RFA treatment success in individuals with clinically suspected VEP. In patients with a less advanced degenerative disc disease (DDD) profile, a>50% area of the endplate with bone marrow intensity changes (BMIC) was predictive of treatment success (OR 4.689). Both regressions areas under the curve (AUCs) were under 70%, indicating low predictive value. All other vertebral endplate, intervertebral disc, nerve roots facet joint, spinal segmental alignment, neuroforamina, lateral recesses, and central canal MRI characteristics were not associated with BVN RFA success.CONCLUSIONS: In patients with vertebrogenic low back pain with Modic changes, the presence of degenerative findings of the anterior and posterior column was not associated with a clinically important impact on BVN RFA treatment success. None of the models demonstrated strong predictive value, indicating that the use of objective imaging biomarkers (Type 1 and/or 2 Modic changes) and a correlating presentation of pain remain the most useful patient selection factors for BVN RFA.

  View details for DOI 10.1093/pm/pnac093

  View details for PubMedID 35856328

• Vertebrogenic Pain: A Paradigm Shift in Diagnosis and Treatment of Axial Low Back Pain. Pain medicine (Malden, Mass.) Conger, A., Smuck, M., Truumees, E., Lotz, J. C., DePalma, M. J., McCormick, Z. L. 2022; 23 (Supplement_2): S63-S71

  View details for DOI 10.1093/pm/pnac081

  View details for PubMedID 35856329

• 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

• Prospective, randomized, multicenter study of intraosseous basivertebral nerve ablation for the treatment of chronic low back pain: 24-Month treatment arm results. North American Spine Society journal Koreckij, T., Kreiner, S., Khalil, J. G., Smuck, M., Markman, J., Garfin, S., INTRACEPT Trial Investigators 2021; 8: 100089

  Abstract

  Background: Vertebral endplates, innervated by the basivertebral nerve, can be a source of vertebrogenic low back pain when damaged with inflammation, visible as types 1 or 2 Modic changes. A randomized controlled trial (RCT) compared basivertebral nerve ablation (BVNA) to standard care (SC) showed significant differences between arms at 3 and 6-months. At 12-months, significant improvements were sustained for BVNA. We report results of the BVNA arm at 24-months.Methods: Prospective, open label, single-arm follow-up of the BVNA treatment arm of a RCT in 20 US sites with visits at 6-weeks, and 3, 6, 9, 12 and 24-months. Paired comparisons to baseline were made for the BVNA arm at each timepoint for Oswestry Disability Index (ODI), Visual Analog Scale (VAS), Short Form Health Survey (SF-36), EQ-5D-5L, and responder rates.Results: 140 patients were randomized, 66 to BVNA. In the 58 BVNA patients completing a 24-month visit, 67% had back pain for >5 years, 36% were actively taking opioids at baseline, 50% had prior epidural steroid injections, and 12% had prior low back surgery. Improvements in ODI, VAS, SF-36 PCS, and EQ-5D-5L were statistically significant at all timepoints through 2 years. At 24 months, ODI and VAS improved 28.5±16.2 points (from baseline 44.5; p<0.001) and 4.1±2.7 cm (from baseline 6.6; p<0.001), respectively. A combined responder rate of ODI≥15 and VAS≥2 was 73.7%. A ≥50% reduction in pain was reported in 72.4% of patients and 31.0% were pain-free at 2 years. At 24 months, only 3(5%) of patients had BVNA-level steroid injections, and 62% fewer patients were actively taking opioids. There were no serious device or device-procedure related adverse events reported through 24 months.Conclusion: Intraosseous BVNA demonstrates an excellent safety profile and significant improvements in pain, function, and quality of life that are sustained through 24 months in patients with chronic vertebrogenic low back pain.

  View details for DOI 10.1016/j.xnsj.2021.100089

  View details for PubMedID 35141653

• What does the Patient with Back Pain Want? A Comparison of Patient Preferences and Physician Assumptions. The spine journal : official journal of the North American Spine Society Smuck, M., Barrette, K., Martinez-Ith, A., Sultana, G., Zheng, P. 2021

  Abstract

  BACKGROUD CONTEXT: Low back pain can be difficult to diagnose, leaving patients frustrated and confused after medical visits.PURPOSE: To evaluate the importance of reasons for seeking care in patients with back pain, and to compare this to physicians' assumptions about these patients' reasons.STUDY DESIGN/SETTING: Prospective survey study carried out at two Academic Spine Centers.PATIENT SAMPLE: 419 patients with back pain upon initial presentation to a spine clinic, and 198 physicians; all volunteered to complete a survey.OUTCOME MEASURES: Variance in mean values between patient and physician responders with significance determined by non-overlapping 95% confidence intervals.METHODS: Patients were asked to "rate each of the following with regard to their importance to you" (answering between 0 "not important" to 4 "extremely important"): improvement in level of pain, improvement in ability to perform daily tasks, explanation of what is causing your problem, thorough physical examination, diagnostic testing, medication, physical therapy, surgery. Physicians were asked to rate each of these "with regard to their importance to your patients."RESULTS: Patients indicated the following items were the most important (mean values): explanation of what is causing your problem (3.27), improvement in level of pain (3.48) and improvement in ability to perform daily tasks (3.31). Patients attributed the least importance and lowest scores to: surgery (1.07) and medication (1.89). Comparing the mean values to each item by patient and physician responders revealed statistically significant differences in certain items. Specifically, physicians underestimated the importance of an explanation of what is causing the problem (2.78 ± 0.119 vs. 3.28 ± 0.098, 95% CI) and overvalued diagnostic tests (2.64 ± 0.120 vs. 2.30 ± 0.147, 95% CI), medications (2.38 ± 0.118 vs. 1.89 ± 0.143, 95% CI) and surgery (1.60 ± 0.126 vs 1.07 ± 0.140, 95% CI).CONCLUSION: Patients did not place as much importance on diagnostic tests, medications and surgery as the physicians assumed. Physicians understand that back pain patients want improvement in both pain and function, but they underestimate the importance of an explanation for the pain.

  View details for DOI 10.1016/j.spinee.2021.09.007

  View details for PubMedID 34551322

• Examining the Association Between Self-Reported Estimates of Function and Objective Measures of Gait and Physical Capacity in Lumbar Stenosis. Archives of rehabilitation research and clinical translation Odonkor, C. A., Taraben, S., Tomkins-Lane, C., Zhang, W., Muaremi, A., Leutheuser, H., Sun, R., Smuck, M. 2021; 3 (3): 100147

  Abstract

  Objective: To evaluate the association of self-reported physical function with subjective and objective measures as well as temporospatial gait features in lumbar spinal stenosis (LSS).Design: Cross-sectional pilot study.Setting: Outpatient multispecialty clinic.Participants: Participants with LSS and matched controls without LSS (n=10 per group; N=20).Interventions: Not applicable.Main Outcome Measures: Self-reported physical function (36-Item Short Form Health Survey [SF-36] physical functioning domain), Oswestry Disability Index, Swiss Spinal Stenosis Questionnaire, the Neurogenic Claudication Outcome Score, and inertia measurement unit (IMU)-derived temporospatial gait features.Results: Higher self-reported physical function scores (SF-36 physical functioning) correlated with lower disability ratings, neurogenic claudication, and symptom severity ratings in patients with LSS (P<.05). Compared with controls without LSS, patients with LSS have lower scores on physical capacity measures (median total distance traveled on 6-minute walk test: controls 505 m vs LSS 316 m; median total distance traveled on self-paced walking test: controls 718 m vs LSS 174 m). Observed differences in IMU-derived gait features, physical capacity measures, disability ratings, and neurogenic claudication scores between populations with and without LSS were statistically significant.Conclusions: Further evaluation of the association of IMU-derived temporospatial gait with self-reported physical function, pain related-disability, neurogenic claudication, and spinal stenosis symptom severity score in LSS would help clarify their role in tracking LSS outcomes.

  View details for DOI 10.1016/j.arrct.2021.100147

  View details for PubMedID 34589697

• PHYSICAL ACTIVITY THRESHOLDS FOR PREDICTING LONGITUDINAL GAIT DECLINE IN ADULTS WITH KNEE OSTEOARTHRITIS Sun, R., Tomkins-Lane, C., Muaremi, A., Kuwabara, A., Smuck, M. ELSEVIER SCI LTD. 2021: S17

  View details for Web of Science ID 000680843400024

• Intraosseous Basivertebral Nerve Radiofrequency Ablation for the Treatment of Vertebral Body Endplate Low Back Pain: Current Evidence and Future Directions. Pain medicine (Malden, Mass.) Michalik, A., Conger, A., Smuck, M., Maus, T. P., McCormick, Z. L. 2021; 22 (Supplement_1): S24-S30

  Abstract

  Recently, basivertebral nerve (BVN) radiofrequency ablation has been developed for the treatment of chronic low back pain (CLBP) thought to arise from the vertebral body endplates (VEPs). This review describes the relevant neuroanatomy and pathobiology of VEP degeneration and injury, imaging correlates of presumed VEP pain, randomized controlled trials performed, appropriate patient selection, and safety. Anatomic, histological, and clinical evidence supports the concept of the VEP as a source of CLBP and the nociceptive role of the BVN. BVN radiofrequency ablation appears to be an effective treatment for a subset of patients with CLBP and evidence of Modic change types 1 and 2 in the L3 to S1 VEPs who have failed to respond to conservative treatment. However, all studies performed to date have been industry sponsored, and future non-industry-funded trials will be needed to confirm these results.

  View details for DOI 10.1093/pm/pnab117

  View details for PubMedID 34308955

• Prospective, randomized, multicenter study of intraosseous basivertebral nerve ablation for the treatment of chronic low back pain: 12-month results. Regional anesthesia and pain medicine Smuck, M., Khalil, J., Barrette, K., Hirsch, J. A., Kreiner, S., Koreckij, T., Garfin, S., Mekhail, N., INTRACEPT Trial Investigators, Beall, D., Bainbridge, S., Khalil, J., Koreckij, T., Kalapos, P., Phillips, F., Keel, J., Wang, J., Smuck, M., Munyon, C., Markman, J., Vrooman, B., Anand, N., Lieberman, D., Shannon, L., Kreiner, S., Calodney, A., Yonemura, K., Goodman, B., Moore, G., Schaufele, M., Al Rhyne, D. N. 2021

  Abstract

  INTRODUCTION: Vertebral endplates, innervated by the basivertebral nerve (BVN), are a source of chronic low back pain correlated with Modic changes. A randomized trial comparing BVN ablation to standard care (SC) recently reported results of an interim analysis. Here, we report the results of the full randomized trial, including the 3-month and 6-month between-arm comparisons, 12-month treatment arm results, and 6-month outcomes of BVN ablation in the former SC arm.METHODS: Prospective, open label, 1:1 randomized controlled trial of BVN ablation versus SC in 23 US sites with follow-up at 6 weeks, 3, 6, 9, and 12 months. SC patients were re-baselined and followed up for 6 months post BVN ablation. The primary endpoint was the between-arm comparison of mean Oswestry Disability Index (ODI) change from baseline. Secondary endpoints were Visual Analog Scale (VAS), Short Form (SF-36), EuroQual Group 5 Dimension 5-Level Quality of Life (EQ-5D-5L), responder rates, and rates of continued opioid use.RESULTS: 140 were randomized. Results from BVN ablation (n=66) were superior to SC (n=74) at 3 months for the primary endpoint (mean ODI reduction, difference between arms of -20.3 (CI -25.9 to -14.7 points; p<0.001)), VAS pain improvement (difference of -2.5 cm between arms (CI -3.37 to -1.64, p<0.001)) and quality of life outcomes. At 12 months, basivertebral ablation demonstrated a 25.7±18.5 point reduction in mean ODI (p<0.001), and a 3.8±2.7 cm VAS reduction (p<0.001) from baseline, with 64% demonstrating ≥50% reduction and 29% pain free. Similarly, the former SC patients who elected BVN ablation (92%) demonstrated a 25.9±15.5 point mean ODI reduction (p<0.001) from baseline. The proportion of opioid use did not change in either group (p=0.56).DISCUSSION/CONCLUSION: BVN ablation demonstrates significant improvements in pain and function over SC, with treatment results sustained through 12 months in patients with chronic low back pain of vertebrogenic origin.

  View details for DOI 10.1136/rapm-2020-102259

  View details for PubMedID 34031220

• Physical Activity Thresholds for Predicting Longitudinal Gait Decline in adults with Knee Osteoarthritis. Osteoarthritis and cartilage Sun, R., Tomkins-Lane, C., Muaremi, A., Kuwabara, A., Smuck, M. 2021

  Abstract

  OBJECTIVE: To investigate the longitudinal relationship between physical performance (via real-life accelerometry) and physical capacity (laboratory measurement of gait speed) in patients with knee osteoarthritis (KOA), and to derive accelerometry measured thresholds associated with gait speed decline in KOA that may provide targets for disease-specific physical activity guidelines.DESIGN: Longitudinal data from the Osteoarthritis Initiative (OAI) accelerometer sub-study was extracted from 1229 participants assessed 2 years apart. Extracted data include functional capacity, demographic and anthropometric characteristics, patient-reported outcome measures, and accelerometry-based physical activity measures. A "poor capacity" group was defined based on the gait speed quintile decline between baseline and the 2-yr follow-up. A Random Forest classifier was trained to classify individuals' capacity status, and the impact of each extracted factor on the prediction outcome was analyzed using a novel machine learning interpretation algorithm.RESULTS: The most impactful predicting feature for gait decline is low minutes in the performance of moderate-vigorous activity (count per min 2500+). Slower sit-to-stand performance, higher age and self-reported knee pain, and lower minutes in performance light activities (count per min 350-2499) also contributed to the model prediction. The overall classification accuracy is 76.3% (75.4% sensitivity,76.5% specificity).CONCLUSIONS: We investigated the impact magnitude and direction of each predicting feature on the longitudinal capacity status among KOA patients. Using novel data interpretation method, we established feature thresholds that may increase the probability of gait decline. These identified thresholds may provide meaningful information for establishing specific physical activity guidelines for KOA.

  View details for DOI 10.1016/j.joca.2021.04.002

  View details for PubMedID 33865966

• The emerging clinical role of wearables: factors for successful implementation in healthcare. NPJ digital medicine Smuck, M., Odonkor, C. A., Wilt, J. K., Schmidt, N., Swiernik, M. A. 2021; 4 (1): 45

  Abstract

  Wearable technologies promise to redefine assessment of health behaviors, yet their clinical implementation remains a challenge. To address this gap, two of the NIH's Big Data to Knowledge Centers of Excellence organized a workshop on potential clinical applications of wearables. A workgroup comprised of 14 stakeholders from diverse backgrounds (hospital administration, clinical medicine, academia, insurance, and the commercial device industry) discussed two successful digital health interventions that involve wearables to identify common features responsible for their success. Seven features were identified including: a clearly defined problem, integration into a system of healthcare delivery, technology support, personalized experience, focus on end-user experience, alignment with reimbursement models, and inclusion of clinician champions. Health providers and systems keen to establish new models of care inclusive of wearables may consider these features during program design. A better understanding of these features is necessary to guide future clinical applications of wearable technology.

  View details for DOI 10.1038/s41746-021-00418-3

  View details for PubMedID 33692479

• 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

• Objective features of Sedentary Time and Light Activity Differentiate People with Low Back Pain from Healthy Controls, a Pilot Study. The spine journal : official journal of the North American Spine Society Tomkins-Lane, C., Sun, R., Muaremi, A., Zheng, P., Mohan, M., Ith, M. A., Smuck, M. 2021

  Abstract

  Physical inactivity has been described as both a cause and a consequence of low back pain (LBP) largely based on self-reported measures of daily activity. A better understanding of the connections between routine physical activity and LBP may improve LBP interventions.In this study, we aim to objectively characterize the free-living physical activity of people with low back pain in comparison to healthy controls using accelerometers, and we aim to derive a set of LBP-specific physical activity minutes thresholds that may be used as targets for future physical activity interventions.Cross-sectional PATIENT SAMPLE: 22 low back pain patients and 155 controls.Accelerometry derived physical activity measures.Twenty-two people with LBP were compared to 155 age and gender-matched healthy controls. All subjects wore an ActiGraph accelerometer on the right hip for 7-consecutive days. Accelerometry-based physical activity features (count-per-minute CPM) were derived using Freedson's intervals and physical performance intervals.  A random forest machine learning classifier was trained to classify LBP status using a leave-one-out cross-validation procedure. An interpretation algorithm, the SHapley Additive exPlanations (SHAP) algorithm was subsequently applied to assess the feature importance and to establish LBP-specific physical activity thresholds.The LBP group reported mild to moderate disability (average ODI=18.5). The random forest classifier identified a set of 8 features (digital biomarkers) that achieved 88.1% accuracy for distinguishing LBP from controls.  All of the top distinguishing features were related to differences in the sedentary and light activity ranges (<800 CPM), whereas moderate to vigorous physical activity was not discriminative. In addition, we identified and ranked physical activity thresholds that are associated with LBP prediction that can be used in future studies of physical activity interventions for LBP.We describe a set of physical activity features from accelerometry data associated with LBP. All of the discriminating features were derived from the sedentary and light activity range.  We also identified specific activity intensity minutes thresholds that distinguished LBP subjects from healthy controls.Future examination on the digital markers and thresholds identified through this work can be used to improve physical activity interventions for LBP treatment and prevention by allowing the development of LBP-specific physical activity guidelines.

  View details for DOI 10.1016/j.spinee.2021.11.005

  View details for PubMedID 34798245

• Skin Mountable Capillaric Strain Sensor with Ultrahigh Sensitivity and Direction Specificity ADVANCED MATERIALS TECHNOLOGIES Rivas Yepes, L., Demir, E., Lee, J., Sun, R., Smuck, M., Araci, I. 2020

  View details for DOI 10.1002/admt.202000631

  View details for Web of Science ID 000584080800001

• Preoperative epidural steroid injections are not associated with increased rates of infection and dural tear in lumbar spine surgery. European spine journal : official publication of the European Spine Society, the European Spinal Deformity Society, and the European Section of the Cervical Spine Research Society Koltsov, J. C., Smuck, M. W., Alamin, T. F., Wood, K. B., Cheng, I., Hu, S. S. 2020

  Abstract

  PURPOSE: The study objectives were to use a large national claims data resource to examine rates of preoperative epidural steroid injections (ESI) in lumbar spine surgery and determine whether preoperative ESI or the timing of preoperative ESI is associated with rates of postoperative complications and reoperations.METHODS: A retrospective longitudinal analysis of patients undergoing lumbar spine surgery for disc herniation and/or spinal stenosis was undertaken using the MarketScan databases from 2007-2015. Propensity-score matched cohorts were constructed to compare rates of complications and reoperations in patients with and without preoperative ESI.RESULTS: Within the year prior to surgery, 120,898 (46.4%) patients had a lumber ESI. The median time between ESI and surgery was 10weeks. 23.1% of patients having preoperative ESI had more than one level injected, and 66.5% had more than one preoperative ESI treatment. Patients with chronic pain were considerably more likely to have an ESI prior to their surgery [OR 1.62 (1.54, 1.69), p<0.001]. Patients having preoperative ESI within in close proximity to surgery did not have increased rates of infection, dural tear, neurological complications, or surgical complications; however, they did experience higher rates of reoperations and readmissions than those with no preoperative ESI (p<0.001).CONCLUSION: Half of patients undergoing lumbar spine surgery for stenosis and/or herniation had a preoperative ESI. These were not associated with an increased risk for postoperative complications, even when the ESI was given in close proximity to surgery. Patients with preoperative ESI were more likely to have readmissions and reoperations following surgery.

  View details for DOI 10.1007/s00586-020-06566-6

  View details for PubMedID 32789696

• Predicting Poor Functional Status In Adults With Knee Osteoarthritis Using Real-life Accelerometry Data Sun, R., Kuwabara, A., Tomkins-Lane, C., Smuck, M. LIPPINCOTT WILLIAMS & WILKINS. 2020: 823–24

  View details for Web of Science ID 000590026303305

• Cervical Epidural Steroid Injections: Incidence and Determinants of Subsequent Surgery. The spine journal : official journal of the North American Spine Society Kleimeyer, J. P., Koltsov, J. C., Smuck, M. W., Wood, K. B., Cheng, I., Hu, S. S. 2020

  Abstract

  BACKGROUND CONTEXT: Cervical epidural steroid injections (CESIs) are sometimes used in the management of cervical radicular pain in order to delay or avoid surgery. However, the rate and determinants of surgery following CESIs remain uncertain.PURPOSE: This study sought to determine: 1) the proportion of patients having surgery following CESI, and 2) the timing of and factors associated with subsequent surgery.STUDY DESIGN: Retrospective analysis of a large, national administrative claims database.PATIENT SAMPLE: The study included 192,777 CESI patients (age 50.9±11.3 years, 55.2% female) who underwent CESI for imaging-based diagnoses of cervical disc herniation or stenosis, a clinical diagnosis of radiculopathy, or a combination thereof.OUTCOME MEASURES: The primary outcome was the time from index CESI to surgery.METHODS: Inclusion criteria were CESI for cervical disc herniation, stenosis, or radiculopathy, age ≥18, and active enrollment for 1 year prior to CESI to screen for exclusions. Patients were followed until they underwent cervical surgery, or their enrollment lapsed. Rates of surgery were assessed with Kaplan-Meier survival curves and 99% confidence intervals. Factors associated with subsequent surgery were assessed with multivariable Cox proportional hazard models.RESULTS: Within 6 months of CESI, 11.2% of patients underwent surgery, increasing to 14.5% by 1 year and 22.3% by 5 years. Male patients and those aged 35-54 had an increased likelihood of subsequent surgery. Patients with radiculopathy were less likely to undergo surgery following CESI than those with stenosis or herniation, while patients with multiple diagnoses were more likely. Patients with comorbidities including CHF, other cardiac comorbidities or chronic pain were less likely to undergo surgery, as were patients in the northeast US region. Some 33.5% of patients underwent >1 CESI, with 84.6% of these occurring within 1 year. Additional injections were associated with reduced rates of subsequent surgery.CONCLUSIONS: Following CESI, over one in five patients underwent surgery within 5 years. Multiple patient-specific risk factors for subsequent surgery were identified, and patients undergoing repeated injections were at lower risk. Determining which patients may progress to surgery can be used to improve resource utilization and to inform shared decision-making.

  View details for DOI 10.1016/j.spinee.2020.06.012

  View details for PubMedID 32565316

• Variability among Methods and Timing of Pain Assessment Tools for Tracking Improvement of Lumbar Stenosis Patients after Surgery. The spine journal : official journal of the North American Spine Society Tomkins-Lane, C., Zheng, P. Z., Sun, R., Smuck, M. 2020

  Abstract

  BACKGROUND CONTEXT: Many different pain and functional outcomes are used to determine progress after surgical intervention for Lumbar Spinal Stenosis (LSS); it is unknown how these different outcomes correlate, or whether timing of pain measurement is important.PURPOSE: The goal was to determine whether method and timing of pain measurement is important in the context of LSS surgical outcomes.STUDY DESIGN/SETTING: Cohort Study.PATIENT SAMPLE: Lumbar Spinal Stenosis (LSS) patients (N=21) OUTCOME MEASURES: Self-report Measures.METHODS: Each patient completed the 36-item Short Form (SF-36), Oswestry Disability Index (ODI), and Swiss Spinal Stenosis Questionnaire (SSSQ) 1 week pre-surgery and 6 months post-surgery. Objective function was measured using the Self-Paced Walking Test (SPWT). Low back and leg pain were assessed by Visual Analogue Scale (VAS) both immediately before the SPWT (pre-walking pain) and at the symptom-limited endpoint (provoked pain). Pain was also assessed before and after surgery using the pain subscales of SF-36 pain, ODI, and SSSQ.RESULTS: Patients averaged 65.3 years of age with 15 being female. After surgery, all outcome measures improved significantly. Post-walking pain (provoked pain) demonstrating a strong relationship with objectively measured function (SPWT). Pain (VAS pre-walk and post-walk) showed little correlation with reported changes in disability, general health or physical function.CONCLUSIONS: Our results suggest that for patients with (LSS), the context of the pain measurement matters, and it is important to measure pain after walking (provoked pain). Results also suggest that when examining the relationship between pain and function, objective measures of function are preferable (e.g. a walking test). Finally, given the lack of association between measures of pain, it is important to understand that each pain measure is addressing a different pain construct. Therefore, when conducting outcomes studies, it is imperative to compare the exact same pain measures across time points.

  View details for DOI 10.1016/j.spinee.2020.06.003

  View details for PubMedID 32534134

• Approaching the Management of Expectations in Patients with Chronic Low Back Pain: Enthusiasm vs Realism. Pain medicine (Malden, Mass.) McCormick, Z. L., Schneider, B. J., Prather, H., Sullivan, W., Smuck, M. 2020

  View details for DOI 10.1093/pm/pnaa144

  View details for PubMedID 32488252

• Consensus practice guidelines on interventions for lumbar facet joint pain from a multispecialty, international working group. Regional anesthesia and pain medicine Cohen, S. P., Bhaskar, A., Bhatia, A., Buvanendran, A., Deer, T., Garg, S., Hooten, W. M., Hurley, R. W., Kennedy, D. J., McLean, B. C., Moon, J. Y., Narouze, S., Pangarkar, S., Provenzano, D. A., Rauck, R., Sitzman, B. T., Smuck, M., van Zundert, J., Vorenkamp, K., Wallace, M. S., Zhao, Z. 2020

  Abstract

  BACKGROUND: The past two decades have witnessed a surge in the use of lumbar facet blocks and radiofrequency ablation (RFA) to treat low back pain (LBP), yet nearly all aspects of the procedures remain controversial.METHODS: After approval by the Board of Directors of the American Society of Regional Anesthesia and Pain Medicine, letters were sent to a dozen pain societies, as well as representatives from the US Departments of Veterans Affairs and Defense. A steering committee was convened to select preliminary questions, which were revised by the full committee. Questions were assigned to 4-5 person modules, who worked with the Subcommittee Lead and Committee Chair on preliminary versions, which were sent to the full committee. We used a modified Delphi method, whereby the questions were sent to the committee en bloc and comments were returned in a non-blinded fashion to the Chair, who incorporated the comments and sent out revised versions until consensus was reached.RESULTS: 17 questions were selected for guideline development, with 100% consensus achieved by committee members on all topics. All societies except for one approved every recommendation, with one society dissenting on two questions (number of blocks and cut-off for a positive block before RFA), but approving the document. Specific questions that were addressed included the value of history and physical examination in selecting patients for blocks, the value of imaging in patient selection, whether conservative treatment should be used before injections, whether imaging is necessary for block performance, the diagnostic and prognostic value of medial branch blocks (MBB) and intra-articular (IA) injections, the effects of sedation and injectate volume on validity, whether facet blocks have therapeutic value, what the ideal cut-off value is for a prognostic block, how many blocks should be performed before RFA, how electrodes should be oriented, the evidence for larger lesions, whether stimulation should be used before RFA, ways to mitigate complications, if different standards should be applied to clinical practice and clinical trials and the evidence for repeating RFA (see table 12 for summary).CONCLUSIONS: Lumbar medial branch RFA may provide benefit to well-selected individuals, with MBB being more predictive than IA injections. More stringent selection criteria are likely to improve denervation outcomes, but at the expense of more false-negatives. Clinical trials should be tailored based on objectives, and selection criteria for some may be more stringent than what is ideal in clinical practice.

  View details for DOI 10.1136/rapm-2019-101243

  View details for PubMedID 32245841

• PREDICTING DECLINE IN CLINICAL GAIT SPEED IN ADULTS WITH KNEE OSTEOARTHRITIS USING BASELINE PHYSICAL ACTIVITY DATA Sun, R., Muaremi, A., Kuwabara, A., Tomkins-Lane, C., Smuck, M. ELSEVIER SCI LTD. 2020: S314

  View details for Web of Science ID 000527813600471

• Digital care for chronic musculoskeletal pain: a 10,000 user longitudinal observational study. Journal of medical Internet research Bailey, J. F., Agarwal, V., Zheng, P., Smuck, M., Fredericson, M., Kennedy, D. J., Krauss, J. 2020

  Abstract

  BACKGROUND: Chronic musculoskeletal pain has a vast global prevalence and economic burden. Conservative therapies are universally recommended but require patient engagement and self-management to be effective.OBJECTIVE: To evaluate the efficacy of a 12-week digital care pathway (DCP) in a large population of patients with chronic knee and back pain.METHODS: A longitudinal observational study using a remote DCP available through employers using a mobile application. Subjects participated in a 12-week multi-modal DCP administered via a mobile app incorporating education, sensor-guided exercise therapy, and behavioral health support with 1-on-1 remote health coaching. Primary outcome was visual analogue scale (VAS) pain. Secondary measures included engagement levels, program completion, program satisfaction, condition-specific pain measures, depression, anxiety, and work productivity.RESULTS: 10,264 adults with either knee (n=3796) or low back (n=6468) pain for at least three months were included in the study. Participants experienced 68.45% average improvement in VAS pain between baseline intake and 12 weeks. 73.1% of all participants completed the DCP into the final month. 78.6% of program completers (69.6% of all participants) achieved minimally important change in pain. Furthermore, the number of exercise therapy sessions and coaching interactions were both positively associated with improvement in pain, supporting that the amount of engagement influenced outcomes. Secondary outcomes included 57.9% and 58.3% decrease in depression and anxiety scores, respectively, and 61.5% improvement in work productivity. Lastly, three distinct clusters of pain response trajectories were identified which could be predicted with mean 76% accuracy using baseline measures.CONCLUSIONS: These results support the efficacy and scalability of a DCP for chronic low back and knee pain in a large, diverse, real-world population. Participants demonstrated high completion and engagement rates, and a significant positive relationship between engagement and pain reduction was identified, a finding which has not been previously demonstrated in a DCP. Furthermore, the large sample size allowed for identification of distinct pain response subgroups which may prove beneficial in predicting recovery and tailoring future interventions. This is the first longitudinal digital health study to analyze pain outcomes in a sample of this magnitude, and it supports the prospect for DCPs to serve the overwhelming number of musculoskeletal pain sufferers worldwide.CLINICALTRIAL:

  View details for DOI 10.2196/18250

  View details for PubMedID 32208358

• Spine Nonoperative Cost Before Surgery. Spine Schneider, B. J., Sullivan, W. n., Prather, H. n., Smuck, M. n., McCormick, Z. n. 2020

  View details for DOI 10.1097/BRS.0000000000003388

  View details for PubMedID 31977674

• Who is physically active? : Classification and Analysis of Physical Activity using NHANES data Nu, U., Touati, T., Buddhadev, S., Sun, R., Smuck, M., Song, I., IEEE IEEE. 2020: 527-533

  View details for Web of Science ID 000682772900070

• TO THE EDITOR. Spine Schneider, B. J., Sullivan, W. n., Prather, H. n., Smuck, M. n., McCormick, Z. n. 2020; 45 (7): E412–E413

  View details for DOI 10.1097/BRS.0000000000003388

  View details for PubMedID 32168137

• 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

• Gait features for discriminating between mobility-limiting musculoskeletal disorders: Lumbar spinal stenosis and knee osteoarthritis. Gait & posture Odonkor, C. n., Kuwabara, A. n., Tomkins-Lane, C. n., Zhang, W. n., Muaremi, A. n., Leutheuser, H. n., Sun, R. n., Smuck, M. n. 2020; 80: 96–100

  Abstract

  Functional ambulation limitations are features of lumbar spinal stenosis (LSS) and knee osteoarthritis (OA). With numerous validated walking assessment protocols and a vast number of spatiotemporal gait parameters available from sensor-based assessment, there is a critical need for selection of appropriate test protocols and variables for research and clinical applications.In patients with knee OA and LSS, what are the best sensor-derived gait parameters and the most suitable clinical walking test to discriminate between these patient populations and controls?We collected foot-mounted inertial measurement unit (IMU) data during three walking tests (fast-paced walk test-FPWT, 6-min walk test- 6MWT, self-paced walk test - SPWT) for subjects with LSS, knee OA and matched controls (N = 10 for each group). Spatiotemporal gait characteristics were extracted and pairwise compared (Omega partial squared - ωp2) between patients and controls.We found that normal paced walking tests (6MWT, SPWT) are better suited for distinguishing gait characteristics between patients and controls. Among the sensor-based gait parameters, stance and double support phase timing were identified as the best gait characteristics for the OA population discrimination, whereas foot flat ratio, gait speed, stride length and cadence were identified as the best gait characteristics for the LSS population discrimination.These findings provide guidance on the selection of sensor-derived gait parameters and clinical walking tests to detect alterations in mobility for people with LSS and knee OA.

  View details for DOI 10.1016/j.gaitpost.2020.05.019

  View details for PubMedID 32497982

• 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

• Smoking Is Associated with Pain in All Body Regions, with Greatest Influence on Spinal Pain. Pain medicine (Malden, Mass.) Smuck, M., Schneider, B. J., Ehsanian, R., Martin, E., Kao, M. J. 2019

  Abstract

  OBJECTIVE: Examine the interrelationship between smoking and pain in the US population.DESIGN: A cross-sectional population-based study.SETTING: Nationwide survey.METHODS: Comprehensive pain reports categorically defined as head, spine, trunk, and limb pain; smoking history; demographics; medical history from a total of 2,307 subjects from the 2003-2004 National Health and Nutrition Examination Survey obtained from the Centers for Disease Control were analyzed. Unpaired t tests were used to analyze independent continuous variables, and chi-square tests were used to analyze categorical variables between smoker and nonsmoker groups. Weighted multivariate logistic regression analyses determined the association of current smoking with the presence of pain in various body regions.RESULTS: Smoking is most strongly associated with spine pain (odds ratio [OR] = 2.89, 95% confidence interval [CI] = 2.21-3.77), followed by headache (OR = 2.47, 95% CI = 1.73-3.53), trunk pain (OR = 2.17, 95% CI = 1.45-2.74), and limb pain (OR = 1.99, 95% CI = 1.45-2.73).CONCLUSIONS: Current smoking is associated with pain in every region of the body. This association is strongest for spine and head pain. Given that pain is a strong motivator and that current smoking was associated with pain in all body regions, we recommend that these results be used to further raise public awareness about the potential harms of smoking.

  View details for DOI 10.1093/pm/pnz224

  View details for PubMedID 31578562

• A Prospective, Randomized, Multi-Center Study of Intraosseous Basivertebral Nerve Ablation for the Treatment of Chronic Low Back Pain. The spine journal : official journal of the North American Spine Society Khalil, J., Smuck, M., Koreckij, T., Keel, J., Beall, D., Goodman, B., Kalapos, P., Nguyen, D., Garfin, S., INTRACEPT Trial Investigators 2019

  Abstract

  BACKGROUND CONTEXT: Current literature suggests that degenerated or damaged vertebral endplates are a significant cause of chronic low back pain (LBP) that is not adequately addressed by standard care. Prior 2-year data from the treatment arm of a sham-controlled randomized controlled trial (RCT) showed maintenance of clinical improvements at 2 years following radiofrequency (RF) ablation of the basivertebral nerve (BVN).PURPOSE: The purpose of this RCT was to compare the effectiveness of intraosseous RF ablation of the BVN to standard care for the treatment of chronic LBP in a specific subgroup of patients suspected to have vertebrogenic related symptomatology.STUDY DESIGN/SETTING: A prospective, parallel, open label RCT was conducted at 20 U.S. sites.PATIENT SAMPLE: A total of 140 patients with chronic LBP of at least 6 months duration, with Modic Type 1 or 2 vertebral endplate changes between L3 to S1, were randomized 1:1 to undergo either RF ablation of the BVN or continue standard care.OUTCOME MEASURES: Oswestry Disability Index (ODI) was collected at baseline, 3, 6, 9, and 12-months post-procedure. Secondary outcome measures included a 10-point Visual Analog Scale (VAS) for LBP, ODI and VAS responder rates, SF-36, and EQ-5D-5L. The primary endpoint was a between-arm comparison of the mean change in ODI from baseline to 3 months post-treatment.METHODS: Patients were randomized 1:1 to receive RF ablation or to continue standard care. Self-reported patient outcomes were collected using validated questionnaires at each study visit. An interim analysis to assess for superiority was pre-specified and overseen by an independent data management committee (DMC) when a minimum of 60% of patients had completed their 3-month primary endpoint visit.RESULTS: The interim analysis showed clear statistical superiority (p < 0.001) for all primary and secondary patient-reported outcome measures in the RF ablation arm compared to the standard care arm. This resulted in a DMC recommendation to halt enrollment in the study and offer early cross-over to the control arm. These results are comprised of the outcomes of the 104 patients included in the intent-to-treat (ITT) analysis of the 3-month primary endpoint, which included 51 patients in the RF ablation arm and 53 patients in the standard care arm. Baseline ODI was 46.1, VAS was 6.67, and mean age was 50 years. The percentage of patients with LBP symptoms ≥ 5 years was 67.3%. Comparing the RF ablation arm to the standard care arm, the mean changes in ODI at three months were -25.3 points versus -4.4 points, respectively, resulting in an adjusted difference of 20.9 points (p<0.001). Mean changes in VAS were -3.46 versus -1.02, respectively, an adjusted difference of 2.44 cm (p<0.001). In the RF ablation arm, 74.5% of patients achieved a ≥ 10-point improvement in ODI, compared with 32.7% in the standard care arm (p < 0.001).CONCLUSIONS: Minimally invasive RF ablation of the BVN led to significant improvement of pain and function at 3-months in patients with chronic vertebrogenic related LBP.

  View details for DOI 10.1016/j.spinee.2019.05.598

  View details for PubMedID 31229663

• Effect of Injectate Viscosity on Epidural Distribution in Lumbar Transforaminal Epidural Steroid Injection. Pain research & management Choi, J., Kim, N., Smuck, M., Lee, S. H. 2019; 2019: 2651504

  Abstract

  There is no report on the effect of injectate viscosity on epidural distribution for lumbar transforaminal epidural steroid injections (L-TFESIs). The aim of this study was to evaluate the influence of injectate viscosity on the volume needed to reach specific landmarks in L-TFESIs.A prospective, randomized, comparative human study involving 118 patients undergoing L-TFESIs was conducted. The study subjects were divided into two groups by a random selection method: raw viscosity group (RV, n=58) and low viscosity group (LV, n=60). Contrast volumes were recorded as the contrast flow reached specific anatomical landmarks under fluoroscopic guidance.The possibility of delivering the injectate to each landmark showed a positive correlation with the amount and a negative correlation with the viscosity of the injectate. However, for landmarks at the medial aspect of the superior pedicle of the corresponding level of injection and for those beyond the spinous process over the contralateral spinal segment, the influence of viscosity was not statistically significant.The epidural distribution of the contrast agent through the transforaminal approach was most affected by the injectate volume and was also partly affected by the viscosity.

  View details for DOI 10.1155/2019/2651504

  View details for PubMedID 30944685

  View details for PubMedCentralID PMC6421806

• Lumbar epidural steroid injections for herniation and stenosis: incidence and risk factors of subsequent surgery SPINE JOURNAL Koltsov, J. B., Smuck, M. W., Zagel, A., Alamin, T. F., Wood, K. B., Cheng, I., Hu, S. S. 2019; 19 (2): 199–205

  View details for DOI 10.1016/j.spinee.2018.05.034

  View details for Web of Science ID 000455917700011

• 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

• Does the presence of the fibronectin-aggrecan complex predict outcomes from lumbar discectomy for disc herniation? SPINE JOURNAL Smith, M. W., Ith, A., Carragee, E. J., Cheng, I., Alamin, T. F., Golish, S., Mitsunaga, K., Scuderi, G. J., Smuck, M. 2019; 19 (2): E28–E33

  View details for DOI 10.1016/j.spinee.2013.06.064

  View details for Web of Science ID 000455917700006

• Effect of Injectate Viscosity on Epidural Distribution in Lumbar Transforaminal Epidural Steroid Injection Pain Research and Management Choi, J., Kim, N., Smuck, M., Lee, S. 2019; 2019: 6

  View details for DOI 10.1155/2019/2651504

• Digital biomarkers of spine and musculoskeletal disease from accelerometers: Defining phenotypes of free-living physical activity in knee osteoarthritis and lumbar spinal stenosis SPINE JOURNAL Tomkins-Lane, C., Norden, J., Sinha, A., Hu, R., Smuck, M. 2019; 19 (1): 15–23

  Abstract

  Lumbar spinal stenosis (LSS) and knee osteoarthritis (OA) are 2 of the leading causes of disability worldwide. In order to provide disease-specific prescriptions for physical activity, there is a clear need to better understand physical activity in daily life (performance) in these populations.To discover performance phenotypes for LSS and OA by applying novel analytical methods to accelerometry data. Specific objectives include the following: (1) to identify characteristic features (phenotypes) of free-living physical activity unique to individuals with LSS and OA, and (2) to determine which features can best differentiate between these conditions.Leveraging data from 3 existing cross-sectional cohorts, accelerometry signal feature characterization and selection were performed in a computational laboratory.Data from a total of 4,028 individuals were analyzed from the following 3 datasets: LSS Accelerometry Database (n=75); OA Initiative (n=1950); and the 2003 to 2004 National Health and Nutrition Examination Survey (pain-free controls, n=2003).In order to characterize the accelerometry signals, data were examined using (1) standard intervals for counts/minute from Freedson et al. and (2) the physical performance intervals for mobility-limited pain populations. From this, 42 novel accelerometry features were defined and evaluated for significance in discriminating between the groups (LSS, OA, and controls) in order to then determine which sparse set of features best differentiates between the groups. These sparse sets of features defined the performance phenotypes.Accelerometry features and their ability to differentiate between individuals with LSS, OA, and controls.Given age and gender, classification rates were at least 80% accurate (pairwise) between diseased and pain-free populations (LSS vs. controls and OA vs. controls). The most important features to distinguish between disease groups corresponded to measures in the light and sedentary activity intervals. The more subtle classification between diseased populations (LSS vs. OA) was 72% accurate, with light and moderate activity providing the prominent distinguishing features.We describe the discovery of performance phenotypes of LSS and OA from accelerometry data, revealed through a novel set of features that characterize daily patterns of movement in people with LSS and OA. These performance phenotypes provide a new method for analyzing free-living physical activity (performance) in LSS and OA, and provide the groundwork for more personalized approaches to measuring and improving function.

  View details for PubMedID 30025995

• 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

• Guidelines for Composing and Assessing a Paper on the Treatment of Pain: A Practical Application of Evidence-Based Medicine Principles to the Mint Randomized Clinical Trials PAIN MEDICINE McCormick, Z. L., Vorobeychik, Y., Gill, J. S., Kao, M. J., Duszynski, B., Smuck, M., Stojanovic, M. P. 2018; 19 (11): 2127–37

  Abstract

  To perform a thorough assessment of the recently published Mint Trials in order to illustrate how to read and analyze a study critically, according to principles of evidence-based medicine.Narrative review.We have applied the recently published guidelines for composing and assessing studies on the treatment of pain to a recently published article describing a large study that claimed its "findings do not support the use of radiofrequency denervation to treat chronic low back pain." These guidelines describe the critical components of a high-quality manuscript that allows communication of all relevant information from authors to readers.Application of evidence-based medicine principles to the publication describing the Mint Trials reveals significant issues with the methodology and conclusions drawn by the authors. A thorough assessment demonstrates issues with inclusion/exclusion criteria, diagnostic block protocols, radiofrequency neurotomy technique, co-interventions, outcome measurement, power analysis, study sample characteristics, data analysis, and loss to follow-up. A failure to definitively establish a diagnosis, combined with use of an inadequate technique for radiofrequency neurotomy and numerous other methodological flaws, leaves the reader unable to draw meaningful conclusions from the study data.Critical analysis, rooted in principles of evidence-based medicine, must be employed by writers and readers alike in order to encourage transparency and ensure that appropriate conclusions are drawn from study data.

  View details for PubMedID 29579232

• Gait Symmetry Assessment with a Low Back 3D Accelerometer in Post-Stroke Patients. Sensors (Basel, Switzerland) Zhang, W., Smuck, M., Legault, C., Ith, M. A., Muaremi, A., Aminian, K. 2018; 18 (10)

  Abstract

  Gait asymmetry is an important marker of mobility impairment post stroke. This study proposes a new gait symmetry index (GSI) to quantify gait symmetry with one 3D accelerometer at L3 (GSIL3). GSIL3 was evaluated with 16 post stroke patients and nine healthy controls in the Six-Minute-Walk-Test (6-MWT). Discriminative power was evaluated with Wilcoxon test and the effect size (ES) was computed with Cliff's Delta. GSIL3 estimated during the entire 6-MWT and during a short segment straight walk (GSIL3straight) have comparable effect size to one another (ES = 0.89, p < 0.001) and to the symmetry indices derived from feet sensors (|ES| = [0.22, 0.89]). Furthermore, while none of the indices derived from feet sensors showed significant differences between post stroke patients walking with a cane compared to those able to walk without, GSIL3 was able to discriminate between these two groups with a significantly lower value in the group using a cane (ES = 0.70, p = 0.02). In addition, GSIL3 was strongly associated with several symmetry indices measured by feet sensors during the straight walking cycles (Spearman correlation: |rho| = [0.82, 0.88], p < 0.05). The proposed index can be a reliable and cost-efficient post stroke gait symmetry assessment with implications for research and clinical practice.

  View details for PubMedID 30282947

• 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

• Gait Symmetry Assessment with a Low Back 3D Accelerometer in Post-Stroke Patients SENSORS Zhang, W., Smuck, M., Legault, C., Ith, M. A., Muaremi, A., Aminian, K. 2018; 18 (10)

  View details for DOI 10.3390/s18103322

  View details for Web of Science ID 000448661500150

• The Global Spine Care Initiative: public health and prevention interventions for common spine disorders in low- and middle-income communities EUROPEAN SPINE JOURNAL Green, B. N., Johnson, C. D., Haldeman, S., Kane, E. J., Clay, M. B., Griffith, E. A., Castellote, J. M., Smuck, M., Rajasekaran, S., Hurwitz, E. L., Nordin, M., Randhawa, K., Yu, H. 2018; 27: 838–50

  View details for DOI 10.1007/s00586-018-5635-8

  View details for Web of Science ID 000448480000009

• The Global Spine Care Initiative: methodology, contributors, and disclosures EUROPEAN SPINE JOURNAL Johnson, C. D., Haldeman, S., Nordin, M., Chou, R., Cote, P., Hurwitz, E. L., Green, B. N., Kopansky-Giles, D., Randhawa, K., Cedraschi, C., Ameis, A., Acaroglu, E., Aartun, E., Adjei-Kwayisi, A., Ayhan, S., Aziz, A., Bas, T., Blyth, F., Borenstein, D., Brady, O., Brooks, P., Camilleri, C., Castellote, J. M., Clay, M. B., Davatchi, F., Dudler, J., Dunn, R., Eberspaecher, S., Emmerich, J., Farcy, J., Fisher-Jeffes, N., Goertz, C., Grevitt, M., Griffith, E. A., Hajjaj-Hassouni, N., Hartvigsen, J., Hondras, M., Kane, E. J., Laplante, J., Lemeunier, N., Mayer, J., Mior, S., Mmopelwa, T., Modic, M., Moss, J., Mullerpatan, R., Muteti, E., Mwaniki, L., Ngandeu-Singwe, M., Outerbridge, G., Rajasekaran, S., Shearer, H., Smuck, M., Sonmez, E., Tavares, P., Taylor-Vaisey, A., Torres, C., Torres, P., van der Horst, A., Verville, L., Vialle, E., Kumar, G., Vlok, A., Watters, W., Wong, C., Wong, J. J., Yu, H., Yuksel, S. 2018; 27: 786–95

  Abstract

  The purpose of this report is to describe the Global Spine Care Initiative (GSCI) contributors, disclosures, and methods for reporting transparency on the development of the recommendations.World Spine Care convened the GSCI to develop an evidence-based, practical, and sustainable healthcare model for spinal care. The initiative aims to improve the management, prevention, and public health for spine-related disorders worldwide; thus, global representation was essential. A series of meetings established the initiative's mission and goals. Electronic surveys collected contributorship and demographic information, and experiences with spinal conditions to better understand perceptions and potential biases that were contributing to the model of care.Sixty-eight clinicians and scientists participated in the deliberations and are authors of one or more of the GSCI articles. Of these experts, 57 reported providing spine care in 34 countries, (i.e., low-, middle-, and high-income countries, as well as underserved communities in high-income countries.) The majority reported personally experiencing or having a close family member with one or more spinal concerns including: spine-related trauma or injury, spinal problems that required emergency or surgical intervention, spinal pain referred from non-spine sources, spinal deformity, spinal pathology or disease, neurological problems, and/or mild, moderate, or severe back or neck pain. There were no substantial reported conflicts of interest.The GSCI participants have broad professional experience and wide international distribution with no discipline dominating the deliberations. The GSCI believes this set of papers has the potential to inform and improve spine care globally. These slides can be retrieved under Electronic Supplementary Material.

  View details for PubMedID 30151808

• The Global Spine Care Initiative: model of care and implementation EUROPEAN SPINE JOURNAL Johnson, C. D., Haldeman, S., Chou, R., Nordin, M., Green, B. N., Cote, P., Hurwitz, E. L., Kopansky-Giles, D., Acaroglu, E., Cedraschi, C., Ameis, A., Randhawa, K., Aartun, E., Adjei-Kwayisi, A., Ayhan, S., Aziz, A., Bas, T., Blyth, F., Borenstein, D., Brady, O., Brooks, P., Camilleri, C., Castellote, J. M., Clay, M. B., Davatchi, F., Dudler, J., Dunn, R., Eberspaecher, S., Emmerich, J., Farcy, J., Fisher-Jeffes, N., Goertz, C., Grevitt, M., Griffith, E. A., Hajjaj-Hassouni, N., Hartvigsen, J., Hondras, M., Kane, E. J., Laplante, J., Lemeunier, N., Mayer, J., Mior, S., Mmopelwa, T., Modic, M., Moss, J., Mullerpatan, R., Muteti, E., Mwaniki, L., Ngandeu-Singwe, M., Outerbridge, G., Rajasekaran, S., Shearer, H., Smuck, M., Sonmez, E., Tavares, P., Taylor-Vaisey, A., Torres, C., Torres, P., van der Horst, A., Verville, L., Vialle, E., Kumar, G., Vlok, A., Watters, W., Wong, C., Wong, J. J., Yu, H., Yuksel, S. 2018; 27: 925–45

  Abstract

  Spine-related disorders are a leading cause of global disability and are a burden on society and to public health. Currently, there is no comprehensive, evidence-based model of care for spine-related disorders, which includes back and neck pain, deformity, spine injury, neurological conditions, spinal diseases, and pathology, that could be applied in global health care settings. The purposes of this paper are to propose: (1) principles to transform the delivery of spine care; (2) an evidence-based model that could be applied globally; and (3) implementation suggestions.The Global Spine Care Initiative (GSCI) meetings and literature reviews were synthesized into a seed document and distributed to spine care experts. After three rounds of a modified Delphi process, all participants reached consensus on the final model of care and implementation steps.Sixty-six experts representing 24 countries participated. The GSCI model of care has eight core principles: person-centered, people-centered, biopsychosocial, proactive, evidence-based, integrative, collaborative, and self-sustaining. The model of care includes a classification system and care pathway, levels of care, and a focus on the patient's journey. The six steps for implementation are initiation and preparation; assessment of the current situation; planning and designing solutions; implementation; assessment and evaluation of program; and sustain program and scale up.The GSCI proposes an evidence-based, practical, sustainable, and scalable model of care representing eight core principles with a six-step implementation plan. The aim of this model is to help transform spine care globally, especially in low- and middle-income countries and underserved communities. These slides can be retrieved under Electronic Supplementary Material.

  View details for PubMedID 30151805

• The Global Spine Care Initiative: World Spine Care executive summary on reducing spine-related disability in low- and middle-income communities EUROPEAN SPINE JOURNAL Haldeman, S., Nordin, M., Chou, R., Cote, P., Hurwitz, E. L., Johnson, C. D., Randhawa, K., Green, B. N., Kopansky-Giles, D., Acaroglu, E., Ameis, A., Cedraschi, C., Aartun, E., Adjei-Kwayisi, A., Ayhan, S., Aziz, A., Bas, T., Blyth, F., Borenstein, D., Brady, O., Brooks, P., Camilleri, C., Castellote, J. M., Clay, M. B., Davatchi, F., Dudler, J., Dunn, R., Eberspaecher, S., Emmerich, J., Farcy, J., Fisher-Jeffes, N., Goertz, C., Grevitt, M., Griffith, E. A., Hajjaj-Hassouni, N., Hartvigsen, J., Hondras, M., Kane, E. J., Laplante, J., Lemeunier, N., Mayer, J., Mior, S., Mmopelwa, T., Modic, M., Moss, J., Mullerpatan, R., Muteti, E., Mwaniki, L., Ngandeu-Singwe, M., Outerbridge, G., Rajasekaran, S., Shearer, H., Smuck, M., Sonmez, E., Tavares, P., Taylor-Vaisey, A., Torres, C., Torres, P., van der Horst, A., Verville, L., Vialle, E., Kumar, G., Vlok, A., Watters, W., Wong, C., Wong, J. J., Yu, H., Yuksel, S. 2018; 27: 776–85

  Abstract

  Spinal disorders, including back and neck pain, are major causes of disability, economic hardship, and morbidity, especially in underserved communities and low- and middle-income countries. Currently, there is no model of care to address this issue. This paper provides an overview of the papers from the Global Spine Care Initiative (GSCI), which was convened to develop an evidence-based, practical, and sustainable, spinal healthcare model for communities around the world with various levels of resources.Leading spine clinicians and scientists around the world were invited to participate. The interprofessional, international team consisted of 68 members from 24 countries, representing most disciplines that study or care for patients with spinal symptoms, including family physicians, spine surgeons, rheumatologists, chiropractors, physical therapists, epidemiologists, research methodologists, and other stakeholders.Literature reviews on the burden of spinal disorders and six categories of evidence-based interventions for spinal disorders (assessment, public health, psychosocial, noninvasive, invasive, and the management of osteoporosis) were completed. In addition, participants developed a stratification system for surgical intervention, a classification system for spinal disorders, an evidence-based care pathway, and lists of resources and recommendations to implement the GSCI model of care.The GSCI proposes an evidence-based model that is consistent with recent calls for action to reduce the global burden of spinal disorders. The model requires testing to determine feasibility. If it proves to be implementable, this model holds great promise to reduce the tremendous global burden of spinal disorders. These slides can be retrieved under Electronic Supplementary Material.

  View details for PubMedID 30151809

• The Global Spine Care Initiative: public health and prevention interventions for common spine disorders in low- and middle-income communities. European spine journal : official publication of the European Spine Society, the European Spinal Deformity Society, and the European Section of the Cervical Spine Research Society Green, B. N., Johnson, C. D., Haldeman, S., Kane, E. J., Clay, M. B., Griffith, E. A., Castellote, J. M., Smuck, M., Rajasekaran, S., Hurwitz, E. L., Nordin, M., Randhawa, K., Yu, H. 2018

  Abstract

  PURPOSE: The purpose of this study was to develop recommendations for prevention interventions for spinal disorders that could be delivered globally, but especially in underserved areas and in low- and middle-income countries.METHODS: We extracted risk factors, associations, and comorbidities of common spinal disorders (e.g., back and neck pain, spinal trauma, infection, developmental disorders) from a scoping review of meta-analyses and systematic reviews of clinical trials, cohort studies, case control studies, and cross-sectional studies. Categories were informed by the Global Spine Care Initiative (GSCI) classification system using the biopsychosocial model. Risk factors were clustered and mapped visually. Potential prevention interventions for individuals and communities were identified.RESULTS: Forty-one risk factors, 51 associations, and 39 comorbidities were extracted; some were associated with more than one disorder. Interventions were at primary, secondary, tertiary, and quaternary prevention levels. Public health-related actions included screening for osteopenia, avoiding exposure to certain substances associated with spinal disorders, insuring adequate dietary intake for vitamins and minerals, smoking cessation, weight management, injury prevention, adequate physical activity, and avoiding harmful clinical practices (e.g., over-medicalization).CONCLUSION: Prevention principles and health promotion strategies were identified that were incorporated in the GSCI care pathway. Interventions should encourage healthy behaviors of individuals and promote public health interventions that are most likely to optimize physical and psychosocial health targeting the unique characteristics of each community. Prevention interventions that are implemented in medically underserved areas should be based upon best evidence, resource availability, and selected through group decision-making processes by individuals and the community. These slides can be retrieved under Electronic Supplementary Material.

  View details for PubMedID 30099669

• Simple Gait Symmetry Measures Based on Foot Angular Velocity: Analysis in Post Stroke Patients. Conference proceedings : ... Annual International Conference of the IEEE Engineering in Medicine and Biology Society. IEEE Engineering in Medicine and Biology Society. Annual Conference Zhang, W., Smuck, M., Legault, C., Ith, M. A., Muaremi, A., Aminian, K. 2018; 2018: 5442–45

  Abstract

  In this paper, we propose symmetry measures for post stroke assessment based on gait signal profiles from inertial sensors. Ten healthy controls and eight post stroke patients performed 6-Minute Walk Tests while wearing an inertial sensor on top of each shoe. Symmetry measures based on the linear correlation and the normalized sample distance between left and right foot pitch angular velocity showed high discriminating power to differentiate post stroke gait from healthy controls (Cliff's D = 0.95, Wilcoxon test p<0.001). The proposed symmetry measures are simple to estimate and do not require spatiotemporal gait parameters while they provide comparable discriminating power than symmetry measures based on spatiotemporal gait characteristics such as maximum angular velocity and stance ratio of each cycle. The proposed symmetry measures have the potential for generalization in wearable sensor based gait symmetry assessment.

  View details for DOI 10.1109/EMBC.2018.8513585

  View details for PubMedID 30441568

• Lumbar Epidural Steroid Injections for Herniation and Stenosis: Incidence and Risk Factors of Subsequent Surgery. The spine journal : official journal of the North American Spine Society Koltsov, J. C., Smuck, M. W., Zagel, A., Alamin, T. F., Wood, K. B., Cheng, I., Hu, S. S. 2018

  Abstract

  BACKGROUND CONTEXT: Lumbosacral ESIs have increased dramatically despite a narrowing of the clinical indications for use. One potential indication is to avoid or delay surgery, yet little information exists regarding surgery rates after ESI.PURPOSE: The purpose of this research was to determine the proportion of patients having surgery after lumbar epidural steroid injection (ESI) for disc herniation or stenosis and to identify the timing and factors associated with this progression STUDY DESIGN/SETTING: This study was a retrospective review of nationally-representative administrative claims data from the Truven Health MarketScan databases from 2007 - 2014.PATIENT SAMPLE: The study cohort was comprised of 179,025 patients (54±15 years, 48% female) having lumbar epidural steroid injections (ESIs) for diagnoses of stenosis and/or herniation.OUTCOME MEASURES: The primary outcome measure was the time from ESI to surgery.METHODS: Inclusion criteria were ESI for stenosis and/or herniation, age ≥18 years, and health plan enrollment for 1 year prior to ESI to screen for exclusions. Patients were followed longitudinally until they progressed to surgery or had a lapse in enrollment, at which time they were censored. Rates of surgery were assessed with the Kaplan-Meier survival curves. Demographic and treatment factors associated with surgery were assessed with multivariable Cox proportional hazard models. No external funding was procured for this research and the authors' conflicts of interest are not pertinent to the present work.RESULTS: Within 6 months, 12.5% of ESI patients underwent lumbar surgery. By 1 year, 16.9% had surgery, and by 5 years, 26.1% had surgery. Patients with herniation had surgery at rates of up to 5 to 7 fold higher, with the highest rates of surgery in younger patients and those with both herniation and stenosis. Other concomitant spine diagnoses, male sex, previous tobacco use, and residence a rural areas or regions other than the Northeastern United States were associated with higher surgery rates. Medical comorbidities (previous treatment for drug use, CHF, obesity, COPD, hypercholesterolemia, and other cardiac complications) were associated with lower surgery rates.CONCLUSIONS: In the long-term, more than 1 out of every 4 patients undergoing ESI for lumbar herniation or stenosis subsequently had surgery, and nearly 1 of 6 had surgery within the first year. After adjusting for other patient demographics and comorbidities, patients with herniation were more likely have surgery than those with stenosis. The improved understanding of the progression from lumbar ESI to surgery will help to better inform discussions regarding the value of ESI and aid in the shared decision making process.

  View details for PubMedID 29959098

• F-18-FDG PET/MRI in Chronic Sciatica: Early Results Revealing Spinal and Nonspinal Abnormalities JOURNAL OF NUCLEAR MEDICINE Cipriano, P. W., Yoon, D., Gandhi, H., Holley, D., Thakur, D., Hargreaves, B. A., Kennedy, D. J., Smuck, M. W., Cheng, I., Biswal, S. 2018; 59 (6): 967–72

  View details for DOI 10.2967/jnumed.117.198259

  View details for Web of Science ID 000435102600026

• A scoping review of biopsychosocial risk factors and co-morbidities for common spinal disorders PLOS ONE Green, B. N., Johnson, C. D., Haldeman, S., Griffith, E., Clay, M. B., Kane, E. J., Castellote, J. M., Rajasekaran, S., Smuck, M., Hurwitz, E. L., Randhawa, K., Yu, H., Nordin, M. 2018; 13 (6)

  View details for DOI 10.1371/journal.pone.0197987

  View details for Web of Science ID 000433900800058

• Reliability and Validity of Athletes Disability Index Questionnaire CLINICAL JOURNAL OF SPORT MEDICINE Noormohammadpour, P., Khezri, A., Farahbakhsh, F., Mansournia, M., Smuck, M., Kordi, R. 2018; 28 (2): 159–67

  Abstract

  The purpose of this study was to evaluate validity and reliability of a new proposed questionnaire for assessment of functional disability in athletes with low back pain (LBP).Validity and reliability study.Elite athletes participating in different fields of sports.Participants were 165 male and female athletes (between 12 and 50 years old) with LBP.Athlete Disability Index (ADI) Questionnaire which is developed by the authors for assessing LBP-related disability in athletes, Oswestry Disability Index (ODI), and the Roland-Morris Disability Questionnaire (RDQ).Self-reported responses were collected regarding LBP-related disability through ADI, ODI, and RDQ.The test-retest reliability was strong, and intraclass correlation value ranged between 0.74 and 0.94. The Cronbach alpha coefficient value of 0.91 (P < 0.001) demonstrated excellent internal consistency of the questionnaire. The correlation coefficient between ADI and ODI was r = 0.918 (P < 0.0001), between ADI and RDQ was r = 0.669 (P < 0.0001), and between ADI and visual analog scale was r = 0.626 (P < 0.001). According to ODI and RDQ, disability levels were mild in the large majority of subjects (91.5% and 86.0%, respectively). Alternatively, disability assessments by the ADI did not cluster at the mild level and ranged more broadly from mild to very high.The ADI is a reliable and valid instrument for assessing disability in athletes with LBP. Compared with the available LBP disability questionnaires used in the general population, ADI can more precisely stratify the disability levels of athletes due to LBP.

  View details for PubMedID 28107217

• Objective measurement of function following lumbar spinal stenosis decompression reveals improved functional capacity with stagnant real-life physical activity SPINE JOURNAL Smuck, M., Muaremi, A., Zheng, P., Norden, J., Sinha, A., Hu, R., Tomkins-Lane, C. 2018; 18 (1): 15–21

  View details for DOI 10.1016/j.spinee.2017.08.262

  View details for Web of Science ID 000417695000004

• Simple Gait Symmetry Measures Based on Foot Angular Velocity: Analysis in Post Stroke Patients Zhang, W., Smuck, M., Legault, C., Ith, M. A., Muaremi, A., Aminian, K., IEEE IEEE. 2018: 5442-5445

  View details for Web of Science ID 000596231905219

• Inferring Physical Function from Wearable Activity Monitors: Analysis of Activity Data from Patients with Knee Osteoarthritis. JMIR Mhealth Uhealth Agarwal, V., Smuck, M., Tomkins-Lane, C., Shah, N. H. 2018

  View details for DOI 10.2196/11315

• Objective measurement of function following lumbar spinal stenosis decompression reveals improved functional capacity with stagnant real-life physical activity. The spine journal : official journal of the North American Spine Society Smuck, M., Muaremi, A., Zheng, P., Norden, J., Sinha, A., Hu, R., Tomkins-Lane, C. 2018; 18 (1): 15-21

  Abstract

  Lumbar spinal stenosis (LSS) is a prevalent and costly condition associated with significant dysfunction. Alleviation of pain and improvement of function are the primary goals of surgical intervention. Although prior studies have measured subjective improvements in function after surgery, few have examined objective markers of functional improvement.We aimed to objectively measure and quantify changes in physical capacity and physical performance following surgical decompression of LSS.Prospective cohort study.Thirty-eight patients with LSS determined by the treating surgeon's clinical and imaging evaluation, and who were scheduled for surgical treatment, were consecutively recruited at two academic medical facilities, with 28 providing valid data for analysis at baseline and 6 months after surgery.Before surgery and at 6 months after surgery, participants provided 7 days of real-life physical activity (performance) using ActiGraph accelerometers; completed two objective functional capacity measures, the Short Physical Performance Battery and Self-Paced Walking Test; and completed three subjective functional outcome questionnaires, Oswestry Disability Index, Spinal Stenosis Symptom Questionnaire, and Short-Form 36.Physical activity, as measured by continuous activity monitoring, was analyzed as previously described according to the 2008 American Physical Activity Guidelines. Paired t tests were performed to assess for postsurgical changes in all questionnaire outcomes and all objective functional capacity measures. Chi-square analysis was used to categorically assess whether patients were more likely to meet these physical activity recommendations after surgery.Participants were 70.1 years old (±8.9) with 17 females (60.7%) and an average body mass index of 28.4 (±6.2). All subjective measures (Oswestry Disability Index, Spinal Stenosis Symptom Questionnaire, and Short-Form 36) improved significantly at 6 months after surgery, as did objective functional measures of capacity including balance, gait speed, and ambulation distance (Short Physical Performance Battery, Self-Paced Walking Test). However, objectively measured performance (real-life physical activity) did not change following surgery. Although fewer participants qualified as inactive (54% vs. 71%), and more (11% vs. 4%) met the physical activity guideline recommendations at the 6-month follow-up, these differences were not statistically significant (p=.22) CONCLUSIONS: This is the first study, of which we are aware, to objectively evaluate changes in postsurgical performance (real-life physical activity) in people with LSS. We found that at 6 months after surgery for LSS, participants demonstrated significant improvements in self-reported function and objectively measured physical capacity, but not physical performance as measured by continuous activity monitoring. This lack of improvement in performance, despite improvements in self-reported function and objective capacity, suggests a role for postoperative rehabilitation focused specifically on increasing performance after surgery in the LSS population.

  View details for DOI 10.1016/j.spinee.2017.08.262

  View details for PubMedID 28962914

  View details for PubMedCentralID PMC5732871

• Inferring Physical Function From Wearable Activity Monitors: Analysis of Free-Living Activity Data From Patients With Knee Osteoarthritis. JMIR mHealth and uHealth Agarwal, V. n., Smuck, M. n., Tomkins-Lane, C. n., Shah, N. H. 2018; 6 (12): e11315

  Abstract

  Clinical assessments for physical function do not objectively quantify routine daily activities. Wearable activity monitors (WAMs) enable objective measurement of daily activities, but it remains unclear how these map to clinically measured physical function measures.This study aims to derive a representation of physical function from daily measurements of free-living activity obtained through a WAM. In addition, we evaluate our derived measure against objectively measured function using an ordinal classification setup.We defined function profiles representing average time spent in a set of pattern classes over consecutive days. We constructed a function profile using minute-level activity data from a WAM available from the Osteoarthritis Initiative. Using the function profile as input, we trained statistical models that classified subjects into quartiles of objective measurements of physical function as measured through the 400-m walk test, 20-m walk test, and 5 times sit-stand test. Furthermore, we evaluated model performance on held-out data.The function profile derived from minute-level activity data can accurately predict physical performance as measured through clinical assessments. Using held-out data, the Goodman-Kruskal Gamma statistic obtained in classifying performance values in the first quartile, interquartile range, and the fourth quartile was 0.62, 0.53, and 0.51 for the 400-m walk, 20-m walk, and 5 times sit-stand tests, respectively.Function profiles accurately represent physical function, as demonstrated by the relationship between the profiles and clinically measured physical performance. The estimation of physical performance through function profiles derived from free-living activity data may enable remote functional monitoring of patients.

  View details for PubMedID 30394876

• A minimum of 5-year follow-up after lumbar transforaminal epidural steroid injections in patients with lumbar radicular pain due to intervertebral disc herniation SPINE JOURNAL Kennedy, D. J., Zheng, P. Z., Smuck, M., McCormick, Z. L., Huynh, L., Schneider, B. J. 2018; 18 (1): 29–35

  View details for DOI 10.1016/j.spinee.2017.08.264

  View details for Web of Science ID 000417695000006

• A scoping review of biopsychosocial risk factors and co-morbidities for common spinal disorders. PloS one Green, B. N., Johnson, C. D., Haldeman, S., Griffith, E., Clay, M. B., Kane, E. J., Castellote, J. M., Rajasekaran, S., Smuck, M., Hurwitz, E. L., Randhawa, K., Yu, H., Nordin, M. 2018; 13 (6): e0197987

  Abstract

  OBJECTIVE: The purpose of this review was to identify risk factors, prognostic factors, and comorbidities associated with common spinal disorders.METHODS: A scoping review of the literature of common spinal disorders was performed through September 2016. To identify search terms, we developed 3 terminology groups for case definitions: 1) spinal pain of unknown origin, 2) spinal syndromes, and 3) spinal pathology. We used a comprehensive strategy to search PubMed for meta-analyses and systematic reviews of case-control studies, cohort studies, and randomized controlled trials for risk and prognostic factors and cross-sectional studies describing associations and comorbidities.RESULTS: Of 3,453 candidate papers, 145 met study criteria and were included in this review. Risk factors were reported for group 1: non-specific low back pain (smoking, overweight/obesity, negative recovery expectations), non-specific neck pain (high job demands, monotonous work); group 2: degenerative spinal disease (workers' compensation claim, degenerative scoliosis), and group 3: spinal tuberculosis (age, imprisonment, previous history of tuberculosis), spinal cord injury (age, accidental injury), vertebral fracture from osteoporosis (type 1 diabetes, certain medications, smoking), and neural tube defects (folic acid deficit, anti-convulsant medications, chlorine, influenza, maternal obesity). A range of comorbidities was identified for spinal disorders.CONCLUSION: Many associated factors for common spinal disorders identified in this study are modifiable. The most common spinal disorders are co-morbid with general health conditions, but there is a lack of clarity in the literature differentiating which conditions are merely comorbid versus ones that are risk factors. Modifiable risk factors present opportunities for policy, research, and public health prevention efforts on both the individual patient and community levels. Further research into prevention interventions for spinal disorders is needed to address this gap in the literature.

  View details for PubMedID 29856783

• Advice to give advice SPINE JOURNAL Zheng, P. Z., Smuck, M. 2017; 17 (10): 1547–48

  Abstract

  Matthew L. Stevens, Chung-Wei C. Lin, Flavia A. de Carvalho, Kevin Phan, Bart Koes, Chris G. Maher. Advice for acute low back pain: A comparison of what research supports and what guidelines recommend. The Spine Journal, In Press.

  View details for PubMedID 28947012

• A minimum of 5-year follow-up after lumbar transforaminal epidural steroid injections in patients with lumbar radicular pain due to intervertebral disc herniation. The spine journal : official journal of the North American Spine Society Kennedy, D. J., Zheng, P. Z., Smuck, M., McCormick, Z. L., Huynh, L., Schneider, B. J. 2017

  Abstract

  BACKGROUND CONTEXT: Patients with lumbosacral radiculopathy from an intervertebral disc herniation are frequently treated by transforaminal epidural steroid injections (TFESIs). The long-term outcomes of these patients are poorly described.PURPOSE: We aimed to determine the long-term outcomes for a homogenous group of patients with acute unilateral lumbar radicular pain due to single-level herniated nucleus after lumbar epidural steroid injection at ≥5 years.DESIGN: This is a prospective cohort study.PATIENT SAMPLE: Subjects enrolled into a previous reported multi-institutional randomized controlled trial, ≥18 years old with single leg radicular pain rating ≥4/10 for less than 6 months' duration, with radiographic imaging demonstrating an anatomically congruent single-level herniated nucleus pulposus.OUTCOME MEASURES: Presence of recurrent or persistent pain, pain within the previous week, current opioid use for radicular symptoms, additional spine injections for radicular pain, progression to surgery, and unemployment due to pain as determined by independent phone interview at least 5 years after enrolment due to the initial pain complaint were the outcome measures.METHODS: All patients initially underwent a single-level lumbar TFESIs due to failure of conservative care, but could elect to pursue surgical intervention or repeat injections through shared decision making with the treating physician when and if pain control was deemed inadequate. After ≥5 years, an independent assessor contacted the subjects by phone and performed a standardized interview to determine outcomes. Fisher exact test was used to compare outcomes for those who pursued versus those who did not pursue surgery.RESULTS: During the recruitment period (December 2008 to December 2012), 78 subjects were enrolled. At 5 years, 39 (50%) of the 78 subjects were reachable for independent phone follow-up. Of these, 30 (76.9%, 95% confidence interval [CI] 61.7%-87.4%) had a history of recurrent pain since the initial TFESI. However, only 9 (23.1%, 95% CI 12.7%-38.3%) had current pain, while 3 (7.7%, 95% CI 2.7%-20.3%) were currently taking opioid medications. Nine (23.1%, 95% CI 12.7%-38.3%) had received additional TFESIs, and 19 (48.7%, 95% CI 33.9%-63.8%) had received surgery. Only 3 (7.7%, 95% CI 2.7%-20.3%) were unemployed due to related pain at time of follow-up. When comparing the group that had surgery versus those that did not, there were no differences in the rates of recurrent pain (16, 84.2% vs. 14, 70.0%, p=.81), current pain (6, 31.6% vs. 3, 15.0%, p=.47), opioid use (2, 10.5% vs. 1, 5.0%, p=1.00), rate of additional injections (6, 31.6% vs. 3, 15.0%, p=.47), or unemployment status (2, 10.5% vs. 1, 5.0%, p=1.00).CONCLUSIONS: Despite a high success rate at 6 months, the majority of subjects experienced a recurrence of symptoms at some time during the subsequent 5 years. Fortunately, few reported current symptoms, and a small minority required additional injections, surgery, or opioid pain medications. Lumbar disc herniation is a disease that can be effectively treated in the short-term by TFESI or surgery, but long-term recurrence rates are high regardless of treatment received.

  View details for PubMedID 28962912

• Stagnant Physical Therapy Referral Rates Alongside Rising Opioid Prescription Rates in Patients With Low Back Pain in the United States 1997-2010 SPINE Zheng, P., Kao, M., Karayannis, N. V., Smuck, M. 2017; 42 (9): 670-674

  Abstract

  A cross-sectional observational study utilizing the National Ambulatory and National Hospital Ambulatory Medical Care Surveys between 1997 and 2010.The aim of this study was to characterize national physical therapy (PT) referral trends during primary care provider (PCP) visits in the United States.Despite guidelines recommending PT for the initial management of low back pain (LBP), national PT referral rates remain low.Race, ethnicity, age, payer type, and PT referral rates were collected for patients aged 16 to 90 years who were visiting their PCPs. Associations among demographic variables and PT referral were determined using logistic regression.Between 1997 and 2010, we estimated 170 million visits for LBP leading to 17.1 million PT referrals. Average proportion of PCP visits associated with PT referrals remained stable at about 10.1% [odds ratio (OR) 1.00, 95% confidence interval (95% CI) 0.96-1.04)], despite our prior finding of increasing number of visits associated with opioid prescriptions in the same timeframe.Lower PT referral rates were observed among visits by patients who were insured by Medicaid (OR 0.48, 95% CI 0.33-0.69) and Medicare (OR 0.50, 95% CI 0.35-0.72). Furthermore, visits not associated with PT referrals were more likely to be associated with opioid prescriptions (OR 1.69, 95% CI 1.22-2.35).Although therapies delivered by PTs are promoted as a first-line treatment for LBP, PT referral rates remain low. There also exist disparately lower referral rates in populations with more restrictive health plans and simultaneous opioid prescription. Our findings provide a broad overview to PT prescription trend and isolate concerning associations requiring further explorations.3.

  View details for DOI 10.1097/BRS.0000000000001875

  View details for Web of Science ID 000401015100015

  View details for PubMedID 28441685

• App Development for Therapeutic Exercise PM&R Zheng, P., Leff, G., Ith, M., Smuck, M. 2017; 9 (5): S116–S117

  View details for PubMedID 28527496

• Long-Term Effects of Repeated Injections of Local Anesthetic With or Without Corticosteroid for Lumbar Spinal Stenosis: A Randomized Trial. Archives of physical medicine and rehabilitation Friedly, J. L., Comstock, B. A., Turner, J. A., Heagerty, P. J., Deyo, R. A., Bauer, Z., Avins, A. L., Nedeljkovic, S. S., Nerenz, D. R., Shi, X. R., Annaswamy, T., Standaert, C. J., Smuck, M., Kennedy, D. J., Akuthota, V., Sibell, D., Wasan, A. D., Diehn, F., Suri, P., Rundell, S. D., Kessler, L., Chen, A. S., Jarvik, J. G. 2017

  Abstract

  To determine the overall long-term effectiveness of treatment with epidural corticosteroid injections for lumbar central spinal stenosis and the effect of repeat injections, including crossover injections, on outcomes through 12 months.Multicenter, double-blind, randomized controlled trial comparing epidural injections of corticosteroid plus lidocaine versus lidocaine alone.Sixteen clinical sites.Participants with imaging-confirmed lumbar central spinal stenosis (N=400).Participants were randomized to receive either epidural injections with corticosteroid plus lidocaine or lidocaine alone with the option of blinded crossover after 6 weeks to receive the alternate treatment. Participants could receive 1 to 2 injections from 0 to 6 weeks and up to 2 injections from 6 to 12 weeks. After 12 weeks, participants received usual care.Primary outcomes were the Roland-Morris Disability Questionnaire (RDQ) (range, 0-24, where higher scores indicate greater disability) and leg pain intensity (range, 0 [no pain] to 10 [pain as bad as you can imagine]). Secondary outcomes included opioid use, spine surgery, and crossover rates.At 12 months, both treatment groups maintained initial observed improvements, with no significant differences between groups on the RDQ (adjusted mean difference, -0.4; 95% confidence interval [CI], -1.6 to 0.9; P=.55), leg pain (adjusted mean difference, 0.1; 95% CI, -0.5 to 0.7; P=.75), opioid use (corticosteroid plus lidocaine: 41.4% vs lidocaine alone: 36.3%; P=.41), or spine surgery (corticosteroid plus lidocaine: 16.8% vs lidocaine alone: 11.8%; P=.22). Fewer participants randomized to corticosteroid plus lidocaine (30%, n=60) versus lidocaine alone (45%, n=90) crossed over after 6 weeks (P=.003). Among participants who crossed over at 6 weeks, the 6- to 12-week RDQ change did not differ between the 2 randomized treatment groups (adjusted mean difference, -1.0; 95% CI, -2.6 to 0.7; P=.24). In both groups, participants crossing over at 6 weeks had worse 12-month trajectories compared with participants who did not choose to crossover.For lumbar spinal stenosis symptoms, epidural injections of corticosteroid plus lidocaine offered no benefits from 6 weeks to 12 months beyond that of injections of lidocaine alone in terms of self-reported pain and function or reduction in use of opioids and spine surgery. In patients with improved pain and function 6 weeks after initial injection, these outcomes were maintained at 12 months. However, the trajectories of pain and function outcomes after 3 weeks did not differ by injectate type. Repeated injections of either type offered no additional long-term benefit if injections in the first 6 weeks did not improve pain.

  View details for DOI 10.1016/j.apmr.2017.02.029

  View details for PubMedID 28396242

• Physical performance analysis: A new approach to assessing free-living physical activity in musculoskeletal pain and mobility-limited populations. PloS one Smuck, M., Tomkins-Lane, C., Ith, M. A., Jarosz, R., Kao, M. J. 2017; 12 (2)

  Abstract

  Accurate measurement of physical performance in individuals with musculoskeletal pain is essential. Accelerometry is a powerful tool for this purpose, yet the current methods designed to evaluate energy expenditure are not optimized for this population. The goal of this study is to empirically derive a method of accelerometry analysis specifically for musculoskeletal pain populations.We extracted data from 6,796 participants in the 2003-4 National Health and Nutrition Examination Survey (NHANES) including: 7-day accelerometry, health and pain questionnaires, and anthropomorphics. Custom macros were used for data processing, complex survey regression analyses, model selection, and statistical adjustment. After controlling for a multitude of variables that influence physical activity, we investigated whether distinct accelerometry profiles accompany pain in different locations of the body; and we identified the intensity intervals that best characterized these profiles.Unique accelerometry profiles were observed for pain in different body regions, logically clustering together based on proximity. Based on this, the following novel intervals (counts/minute) were identified and defined: Performance Sedentary (PSE) = 1-100, Performance Light 1 (PL1) = 101-350, Performance Light 2 (PL2) = 351-800, Performance Light 3 (PL3) = 801-2500, and Performance Moderate/Vigorous (PMV) = 2501-30000. The refinement of accelerometry signals into these new intervals, including 3 distinct ranges that fit inside the established light activity range, best captures alterations in real-life physical performance as a result of regional pain.These new accelerometry intervals provide a model for objective measurement of real-life physical performance in people with pain and musculoskeletal disorders, with many potential uses. They may be used to better evaluate the relationship between pain and daily physical function, monitor musculoskeletal disease progression, gauge disease severity, inform exercise prescription, and quantify the functional impact of treatments. Based on these findings, we recommend that future studies of pain and musculoskeletal disorders analyze accelerometry output based on these new "physical performance" intervals.

  View details for DOI 10.1371/journal.pone.0172804

  View details for PubMedID 28235039

  View details for PubMedCentralID PMC5325560

• Quantifying the relative change in physical activity after Total Knee Arthroplasty using accelerometer based measurements. AMIA Joint Summits on Translational Science proceedings. AMIA Joint Summits on Translational Science Agarwal, V., Smuck, M., Shah, N. H. 2017; 2017: 463–72

  Abstract

  Osteoarthritis is amongst the top five most disabling conditions affecting Americans over 65 years of age and imposes an annual economic burden estimated at $ 89.1 billion. Nearly half of the cost of care of Osteoarthritis is attributable to hospitalizations for total knee arthroplasties (TKA) and total hip arthroplasties (THA). The current clinical practice relies predominantly on subjective assessment of physical function and pain via patient reported outcome measures (PROM) that have proven inadequate for providing a validated, reliable and responsive measure of TKA outcomes. Wearable activity monitors, which produce a trace of regularly monitored physical activity derived from accelerometer measurements, provide a novel opportunity to objectively assess physical functional status in Osteoarthritis patients. Using data from the Osteoarthritis Initiative (OAI), we demonstrate the feasibility of quantifying the relative change in physical activity patterns in Osteoarthritis subjects using accelerometer based measurements of daily physical activity.

  View details for PubMedID 28815146

• 18F-FDG PET/MRI in Chronic Sciatica: Early Results Revealing Spinal and Non-spinal Abnormalities. Journal of nuclear medicine : official publication, Society of Nuclear Medicine Cipriano, P. n., Yoon, D. n., Gandhi, H. n., Holley, D. n., Thakur, D. n., Ith, M. n., Hargreaves, B. n., Kennedy, D. n., Smuck, M. n., Cheng, I. n., Biswal, S. n. 2017

  Abstract

  Chronic sciatica is a major cause of disability worldwide, but accurate diagnosis of the offending pathology remains challenging. In this report, the feasibility of a fluorodeoxyglucose (18F-FDG) positron emission tomography/magnetic resonance imaging (PET/MRI) approach for improved diagnosis of chronic sciatica is presented. Methods:18F-FDG PET/MRI was performed on 9 chronic sciatica patients and 5 healthy volunteers. Region-of-interest analysis using maximum standardized uptake values (SUVmax) was performed, and 18F-FDG uptake in lesions was compared with the corresponding areas in healthy controls. Results: Significantly increased 18F-FDG uptake was observed in detected lesions of all patients, which was correlated with pain symptoms. 18F-FDG-avid lesions were not only found in impinged spinal nerves, but were also associated with non-spinal causes, such as a facet joint degeneration, pars defect, or a presumed scar neuroma. Conclusion: The feasibility of 18F-FDG PET/MRI for diagnosing pain generators in chronic sciatica has been demonstrated, revealing various possible etiologies.

  View details for PubMedID 29097408

• The Impact of Body Mass Index on Fluoroscopy Time During Lumbar Epidural Steroid Injection; A Multicenter Cohort Study PAIN MEDICINE McCormick, Z. L., Choxi, S. C., Lee, D. T., Marcolina, A., Press, J., Kennedy, D. J., Smuck, M., Walega, D. R., Cushman, D. M. 2017; 18 (1): 25-35

  Abstract

  This study aimed to assess the relationship between BMI and fluoroscopy time during lumbar epidural steroid injections (LESIs) performed for lumbosacral radicular pain.Multicenter retrospective cohort study.Three academic, outpatient pain treatment centers.Patients who underwent fluoroscopically guided LESI.Mean and standard deviation (SD) fluoroscopy time were compared between patients with normal (18.5-24.9 kg/m2), overweight (25.0-29.9 kg/m2), and obese (≥30.0 kg/m2) BMI. Statistical significance was set at P=0.01 due to multiple comparisons.A total of 2,930 procedure encounters were included, consisting of 598 interlaminar LESIs and 2,332 transforaminal LESIs. Fluoroscopy time was significantly longer in the obese patients compared to normal and overweight patients during interlaminar LESI (P < 0.01). Fluoroscopy time was significantly longer with each increasing BMI category in during transforaminal LESI (P < 0.01). These relationships remained when a trainee was involved (P < 0.01; P<0.01), during repeat injections (P < 0.01; P < 0.01), and during bilateral transforaminal LESIs (P < 0.01). While longer fluoroscopy times were required in high BMI categories during L5-S1 transforaminal LESI (P < 0.01), there was no relationship between fluoroscopy time and BMI during L4-L5 and S1 transforaminal LESI (P = 0.02; P = 0.13). Fluoroscopy time during interlaminar LESI compared to transforaminal LESI was significantly lower within all BMI categories (all P<0.01).The findings of this study indicate that fluoroscopy time is increased during interlaminar LESIs and during L5-S1 transforaminal LESIs in patients who are obese. These relationships are not affected by injection number, performance of bilateral injections, or trainee involvement. Further study is needed to determine if this increase in fluoroscopy time is indicative of a clinically significant associated increase in radiation dose.

  View details for DOI 10.1093/pm/pnw050

  View details for Web of Science ID 000397102500004

• Objective measurement of free-living physical activity (performance) in lumbar spinal stenosis: are physical activity guidelines being met? SPINE JOURNAL Norden, J., Smuck, M., Sinha, A., Hu, R., Tomkins-Lane, C. 2017; 17 (1): 26-33

  Abstract

  Research suggests that people with lumbar spinal stenosis (LSS) would benefit from increased physical activity. Yet, to date, we do not have disease-specific activity guidelines for LSS, and the nature of free-living physical activity (performance) in LSS remains unknown. LSS care providers could endorse the 2008 United States Physical Activity Guidelines; however, we do not know if this is realistic. The goal of the present study was to determine the proportion of individuals with LSS meeting the 2008 Guidelines. A secondary goal was to better understand the nature of physical performance in this population.Retrospective study.People from the Lumbar Spinal Stenosis Accelerometry Database, all of whom have both radiographic and clinical LSS and are seeking various treatments for their symptoms.Seven-day accelerometry (functional outcome) and demographics (self-reported).For the present study, we analyzed only baseline data that were obtained before any new treatments. Patients with at least 4 valid days of baseline accelerometry data were included. We determined the proportion of individuals with LSS meeting the 2008 US Physical Activity Guidelines of at least 150 minutes of moderate-vigorous (MV) physical activity per week in bouts of 10 minutes or more. We also used the novel Physical Performance analysis designed by our group to determine time spent in varying intensities of activity. There are no conflicts of interest to disclose.We analyzed data from 75 individuals with a mean age of 68 (SD 9), 37% of whom were male. Three people (4%) were considered Meeting Guidelines (at least 150 MV minutes/week), and 56 (75%) were considered Inactive with not even 1 MV minute/week. With the 10-minute bout requirement removed, 10 of 75 (13%) achieved the 150-minute threshold. The average time spent in sedentary activity was 82%, and of time spent in nonsedentary activity, 99.6% was in the light activity range.In conclusion, the present study confirms that people with symptomatic LSS, neurogenic claudication, walking limitations, and LSS-related disability are extremely sedentary and are not meeting guidelines for physical activity. There is an urgent need for interventions aimed at reducing sedentary behavior and increasing the overall level of physical activity in LSS, not only to improve function but also to prevent diseases of inactivity. The present study suggests that reducing sedentary time, increasing time spent in light intensity activity, and increasing time spent in higher intensities of light activity may be appropriate as initial goals for exercise interventions in people with symptomatic LSS and neurogenic claudication, transitioning to moderate activity when appropriate. Results of the present study also demonstrate the importance of employing disease-specific measures for assessment of performance in LSS, and highlight the potential value of these methods for developing targeted and realistic goals for physical activity. Physical activity goals could be personalized using objective assessment of performance with accelerometry. The present study is one step toward a personalized medicine approach for people with LSS, focusing on increasing physical function.

  View details for DOI 10.1016/j.spinee.2016.10.016

  View details for Web of Science ID 000396451800005

• The Impact of Body Mass Index on Fluoroscopy Time During Lumbar Epidural Steroid Injection; A Multicenter Cohort Study. Pain medicine (Malden, Mass.) McCormick, Z. L., Choxi, S. C., Lee, D. T., Marcolina, A., Press, J., Kennedy, D. J., Smuck, M., Walega, D. R., Cushman, D. M. 2017; 18 (1): 25-35

  Abstract

  This study aimed to assess the relationship between BMI and fluoroscopy time during lumbar epidural steroid injections (LESIs) performed for lumbosacral radicular pain.Multicenter retrospective cohort study.Three academic, outpatient pain treatment centers.Patients who underwent fluoroscopically guided LESI.Mean and standard deviation (SD) fluoroscopy time were compared between patients with normal (18.5-24.9 kg/m2), overweight (25.0-29.9 kg/m2), and obese (≥30.0 kg/m2) BMI. Statistical significance was set at P=0.01 due to multiple comparisons.A total of 2,930 procedure encounters were included, consisting of 598 interlaminar LESIs and 2,332 transforaminal LESIs. Fluoroscopy time was significantly longer in the obese patients compared to normal and overweight patients during interlaminar LESI (P < 0.01). Fluoroscopy time was significantly longer with each increasing BMI category in during transforaminal LESI (P < 0.01). These relationships remained when a trainee was involved (P < 0.01; P<0.01), during repeat injections (P < 0.01; P < 0.01), and during bilateral transforaminal LESIs (P < 0.01). While longer fluoroscopy times were required in high BMI categories during L5-S1 transforaminal LESI (P < 0.01), there was no relationship between fluoroscopy time and BMI during L4-L5 and S1 transforaminal LESI (P = 0.02; P = 0.13). Fluoroscopy time during interlaminar LESI compared to transforaminal LESI was significantly lower within all BMI categories (all P<0.01).The findings of this study indicate that fluoroscopy time is increased during interlaminar LESIs and during L5-S1 transforaminal LESIs in patients who are obese. These relationships are not affected by injection number, performance of bilateral injections, or trainee involvement. Further study is needed to determine if this increase in fluoroscopy time is indicative of a clinically significant associated increase in radiation dose.

  View details for DOI 10.1093/pm/pnw050

  View details for PubMedID 27084415

• Objective measurement of free-living physical activity (performance) in lumbar spinal stenosis: are physical activity guidelines being met? The spine journal : official journal of the North American Spine Society Norden, J., Smuck, M., Sinha, A., Hu, R., Tomkins-Lane, C. 2017; 17 (1): 26-33

  Abstract

  Research suggests that people with lumbar spinal stenosis (LSS) would benefit from increased physical activity. Yet, to date, we do not have disease-specific activity guidelines for LSS, and the nature of free-living physical activity (performance) in LSS remains unknown. LSS care providers could endorse the 2008 United States Physical Activity Guidelines; however, we do not know if this is realistic. The goal of the present study was to determine the proportion of individuals with LSS meeting the 2008 Guidelines. A secondary goal was to better understand the nature of physical performance in this population.Retrospective study.People from the Lumbar Spinal Stenosis Accelerometry Database, all of whom have both radiographic and clinical LSS and are seeking various treatments for their symptoms.Seven-day accelerometry (functional outcome) and demographics (self-reported).For the present study, we analyzed only baseline data that were obtained before any new treatments. Patients with at least 4 valid days of baseline accelerometry data were included. We determined the proportion of individuals with LSS meeting the 2008 US Physical Activity Guidelines of at least 150 minutes of moderate-vigorous (MV) physical activity per week in bouts of 10 minutes or more. We also used the novel Physical Performance analysis designed by our group to determine time spent in varying intensities of activity. There are no conflicts of interest to disclose.We analyzed data from 75 individuals with a mean age of 68 (SD 9), 37% of whom were male. Three people (4%) were considered Meeting Guidelines (at least 150 MV minutes/week), and 56 (75%) were considered Inactive with not even 1 MV minute/week. With the 10-minute bout requirement removed, 10 of 75 (13%) achieved the 150-minute threshold. The average time spent in sedentary activity was 82%, and of time spent in nonsedentary activity, 99.6% was in the light activity range.In conclusion, the present study confirms that people with symptomatic LSS, neurogenic claudication, walking limitations, and LSS-related disability are extremely sedentary and are not meeting guidelines for physical activity. There is an urgent need for interventions aimed at reducing sedentary behavior and increasing the overall level of physical activity in LSS, not only to improve function but also to prevent diseases of inactivity. The present study suggests that reducing sedentary time, increasing time spent in light intensity activity, and increasing time spent in higher intensities of light activity may be appropriate as initial goals for exercise interventions in people with symptomatic LSS and neurogenic claudication, transitioning to moderate activity when appropriate. Results of the present study also demonstrate the importance of employing disease-specific measures for assessment of performance in LSS, and highlight the potential value of these methods for developing targeted and realistic goals for physical activity. Physical activity goals could be personalized using objective assessment of performance with accelerometry. The present study is one step toward a personalized medicine approach for people with LSS, focusing on increasing physical function.

  View details for DOI 10.1016/j.spinee.2016.10.016

  View details for PubMedID 27793759

• Is There a Relationship Between Body Mass Index and Fluoroscopy Time During Cervical Interlaminar Epidural Steroid Injections? Pain medicine McCormick, Z. L., Mattie, R., Ebrahimi, A., Lee, D. T., Marcolina, A., Press, J., Kennedy, D. J., Smuck, M., Walega, D. R., Cushman, D. 2016

  Abstract

  BACKGROUND : The challenge of obtaining medical imaging in individuals with higher body mass index (BMI) is described, but there is minimal data regarding the relationship between BMI and fluoroscopy time during cervical interlaminar epidural steroid injection (CIESI). OBJECTIVE : To determine the relationship between BMI and fluoroscopy time during CIESI. METHODS : Retrospective cohort study of patients who underwent fluoroscopically guided CIESI between January 2014 and February 2015 at an academic pain medicine center. Fluoroscopy time data were collected. Comparisons based on analysis of variance were made between patients with normal (<25.0 kg/m(2)), overweight (25.0-29.9 kg/m(2)), and obese (≥30.0 kg/m(2)) BMI. Of 399 procedure encounters, 366 had documented BMI and fluoroscopy time data and were included for analysis. Mean age (± SD) in this cohort was 53 ± 13 years, including 189 females (52%) and 205 first-time injections. Mean fluoroscopy time for all injections was 18 ± 10 seconds. Separated by categorical BMI class, the mean fluoroscopy time was 18 ± 9 seconds for normal weight patients, 17 ± 10 seconds for overweight patients, and 20 ± 11 seconds for obese patients, respectively. Post hoc analysis showed that fluoroscopy time was significantly longer only in obese compared with overweight patients (P = 0.02). Trainee involvement and first-time vs repeat injection did not significantly alter fluoroscopy time (P = 0.17 and P = 0.12, respectively). CONCLUSIONS : The findings of this study indicate that BMI does not appear to have a clinically significant impact on fluoroscopy time during cervical interlaminar epidural steroid injection procedures. Future study is needed to directly quantify radiation exposure in patients and practitioners, as well as the associated health risk.

  View details for DOI 10.1093/pm/pnw264

  View details for PubMedID 28034968

• Immediate Adverse Events in Interventional Pain Procedures: A Multi-Institutional Study. Pain medicine Carr, C. M., Plastaras, C. T., Pingree, M. J., Smuck, M., Maus, T. P., Geske, J. R., El-Yahchouchi, C. A., McCormick, Z. L., Kennedy, D. J. 2016; 17 (12): 2155-2161

  Abstract

  Interventional procedures directed toward sources of pain in the axial and appendicular musculoskeletal system are performed with increasing frequency. Despite the presence of evidence-based guidelines for such procedures, there are wide variations in practice. Case reports of serious complications such as spinal cord infarction or infection from spine injections lack appropriate context and create a misleading view of the risks of appropriately performed interventional pain procedures.To evaluate adverse event rate for interventional spine procedures performed at three academic interventional spine practices.Quality assurance databases at three academic interventional pain management practices that utilize evidence-based guidelines [1] were interrogated for immediate complications from interventional pain procedures. Review of the electronic medical record verified or refuted the occurrence of a complication. Same-day emergency department transfers or visits were also identified by a records search.Immediate complication data were available for 26,061 consecutive procedures. A radiology practice performed 19,170 epidural steroid (primarily transforaminal), facet, sacroiliac, and trigger point injections (2006-2013). A physiatry practice performed 6,190 spine interventions (2004-2009). A second physiatry practice performed 701 spine procedures (2009-2010). There were no major complications (permanent neurologic deficit or clinically significant bleeding [e.g., epidural hematoma]) with any procedure. Overall complication rate was 1.9% (493/26,061). Vasovagal reactions were the most frequent event (1.1%). Nineteen patients (<0.1%) were transferred to emergency departments for: allergic reactions, chest pain, symptomatic hypertension, and a vasovagal reaction.This study demonstrates that interventional pain procedures are safely performed with extremely low immediate adverse event rates when evidence-based guidelines are observed.

  View details for DOI 10.1093/pm/pnw051

  View details for PubMedID 28025351

• A slap on the back and a pat on the head SPINE JOURNAL Smuck, M. 2016; 16 (12): 1500–1502

  View details for PubMedID 27641488

• ISSLS Prize Winner: Consensus on the Clinical Diagnosis of Lumbar Spinal Stenosis: Results of an International Delphi Study. Spine Tomkins-Lane, C., Melloh, M., Lurie, J., Smuck, M., Battié, M. C., Freeman, B., Samartzis, D., Hu, R., Barz, T., Stuber, K., Schneider, M., Haig, A., Schizas, C., Cheung, J. P., Mannion, A. F., Staub, L., Comer, C., Macedo, L., Ahn, S., Takahashi, K., Sandella, D. 2016; 41 (15): 1239-1246

  Abstract

  Delphi.The aim of this study was to obtain an expert consensus on which history factors are most important in the clinical diagnosis of lumbar spinal stenosis (LSS).LSS is a poorly defined clinical syndrome. Criteria for defining LSS are needed and should be informed by the experience of expert clinicians.Phase 1 (Delphi Items): 20 members of the International Taskforce on the Diagnosis and Management of LSS confirmed a list of 14 history items. An online survey was developed that permits specialists to express the logical order in which they consider the items, and the level of certainty ascertained from the questions. Phase 2 (Delphi Study) Round 1: Survey distributed to members of the International Society for the Study of the Lumbar Spine. Round 2: Meeting of 9 members of Taskforce where consensus was reached on a final list of 10 items. Round 3: Final survey was distributed internationally. Phase 3: Final Taskforce consensus meeting.A total of 279 clinicians from 29 different countries, with a mean of 19 (±SD: 12) years in practice participated. The six top items were "leg or buttock pain while walking," "flex forward to relieve symptoms," "feel relief when using a shopping cart or bicycle," "motor or sensory disturbance while walking," "normal and symmetric foot pulses," "lower extremity weakness," and "low back pain." Significant change in certainty ceased after six questions at 80% (P < .05).This is the first study to reach an international consensus on the clinical diagnosis of LSS, and suggests that within six questions clinicians are 80% certain of diagnosis. We propose a consensus-based set of "seven history items" that can act as a pragmatic criterion for defining LSS in both clinical and research settings, which in the long term may lead to more cost-effective treatment, improved health care utilization, and enhanced patient outcomes.2.

  View details for DOI 10.1097/BRS.0000000000001476

  View details for PubMedID 26839989

  View details for PubMedCentralID PMC4966995

• Is There a Relationship Between Body Mass Index and Fluoroscopy Time During Sacroiliac Joint Injection? A Multicenter Cohort Study. Pain medicine McCormick, Z. L., Cushman, D., Lee, D. T., Scholten, P., Chu, S. K., Babu, A. N., Caldwell, M., Ziegler, C., Ashraf, H., Sundar, B., Clark, R., Gross, C., Cara, J., McCormick, K., Ross, B., Smith, C. C., Press, J., Smuck, M., Walega, D. R. 2016; 17 (7): 1241-1248

  Abstract

  To determine the relationship between BMI and fluoroscopy time during intra-articular sacroiliac joint (SIJ) injections performed for a pain indication.Multicenter retrospective cohort study.Three academic, outpatient pain treatment centers.Patients who underwent fluoroscopy guided SIJ injection with encounter data regarding fluoroscopy time during the procedure and body mass index (BMI).Median and 25-75% Interquartile Range (IQR) fluoroscopy time.459 SIJ injections (350 patients) were included in this study. Patients had a median age of 57 (IQR 44, 70) years, and 72% were female. The median BMI in the normal weight, overweight, and obese groups were 23 (IQR 21, 24), 27 (IQR 26, 29), and 35 (IQR 32, 40), respectively. There was no significant difference in the median fluoroscopy time recorded between these BMI classes (p = 0.45). First-time SIJ injection (p = 0.53), bilateral injection (p = 0.30), trainee involvement (p = 0.47), and new trainee involvement (trainee participation during the first 2 months of the academic year) (p = 0.85) were not associated with increased fluoroscopy time for any of the three BMI categories.Fluoroscopy time during sacroiliac joint injection is not increased in patients who are overweight or obese, regardless of whether a first-time sacroiliac joint injection was performed, bilateral injections were performed, a trainee was involved, or a new trainee was involved.

  View details for DOI 10.1093/pm/pnv051

  View details for PubMedID 26814282

• Detection of Intravascular Injection During Lumbar Medial Branch Blocks: A Comparison of Aspiration, Live Fluoroscopy, and Digital Subtraction Technology PAIN MEDICINE Kennedy, D. J., Mattie, R., Hamilton, A. S., Conrad, B., Smuck, M. 2016; 17 (6): 1031-1036

  Abstract

  Medial branch blocks may have unrecognized vascular uptake potentially resulting in false- negative results.To determine the rate of unintended vascular injection of contrast medium during medial branch blocks (MBB) with digital subtraction (DS) technology in the context of negative vascular uptake as determined by live fluoroscopy.Prospective Study in an academic medical center.344 consecutive MBBs in 80 subjects.The presence of vascular flow as determined by live fluoroscopy and DS technology.Unintended vascular injection of contrast medium was determined on 344 consecutive MBBs in 84 subjects, first using live fluoroscopy followed by DS. If live fluoroscopy initially detected vascular uptake, the needle was repositioned until no vascular flow was detected. Once no vascular uptake was confirmed by live fluoroscopy, a contrast medium was then injected while being visualized with DS to again assess the presence or absence of vascular flow undetected by live fluoroscopy.Live fluoroscopy revealed inadvertent vascular uptake in 38 of the 344 blocks [11% (95% CI 8.0-15%)]. DS uncovered an additional 27 of the 344 blocks [7.8% (95% CI 5.3-11.4%)] with evidence of vascular uptake that were not detected with conventional live fluoroscopy.DS enhances the ability to detect inadvertent vascular flow during medial branch blocks. This study demonstrates that standard live fluoroscopy can miss a small percentage of cases with unintentional vascular uptake during MBB when compared with DS and may contribute to occasional false-negative responses.

  View details for DOI 10.1093/pm/pnv073

  View details for Web of Science ID 000379751800006

• Detection of Intravascular Injection During Lumbar Medial Branch Blocks: A Comparison of Aspiration, Live Fluoroscopy, and Digital Subtraction Technology. Pain medicine Kennedy, D. J., Mattie, R., Scott Hamilton, A., Conrad, B., Smuck, M. 2016; 17 (6): 1031-1036

  Abstract

  Medial branch blocks may have unrecognized vascular uptake potentially resulting in false- negative results.To determine the rate of unintended vascular injection of contrast medium during medial branch blocks (MBB) with digital subtraction (DS) technology in the context of negative vascular uptake as determined by live fluoroscopy.Prospective Study in an academic medical center.344 consecutive MBBs in 80 subjects.The presence of vascular flow as determined by live fluoroscopy and DS technology.Unintended vascular injection of contrast medium was determined on 344 consecutive MBBs in 84 subjects, first using live fluoroscopy followed by DS. If live fluoroscopy initially detected vascular uptake, the needle was repositioned until no vascular flow was detected. Once no vascular uptake was confirmed by live fluoroscopy, a contrast medium was then injected while being visualized with DS to again assess the presence or absence of vascular flow undetected by live fluoroscopy.Live fluoroscopy revealed inadvertent vascular uptake in 38 of the 344 blocks [11% (95% CI 8.0-15%)]. DS uncovered an additional 27 of the 344 blocks [7.8% (95% CI 5.3-11.4%)] with evidence of vascular uptake that were not detected with conventional live fluoroscopy.DS enhances the ability to detect inadvertent vascular flow during medial branch blocks. This study demonstrates that standard live fluoroscopy can miss a small percentage of cases with unintentional vascular uptake during MBB when compared with DS and may contribute to occasional false-negative responses.

  View details for PubMedID 26814308

• [18F]FDG PET/MRI of patients with chronic pain alters management: Early experience. Xu, Y., Yoon, D., Behera, D., Holley, D., Carroll, I., Smuck, M., Hargreaves, B., Mittra, E., Biswal, S. SOC NUCLEAR MEDICINE INC. 2016

  View details for Web of Science ID 000442211000319

• Immediate Adverse Events in Interventional Pain Procedures: A Multi-Institutional Study. Pain medicine Carr, C. M., Plastaras, C. T., Pingree, M. J., Smuck, M., Maus, T. P., Geske, J. R., El-Yahchouchi, C. A., McCormick, Z. L., Kennedy, D. J. 2016

  Abstract

  Interventional procedures directed toward sources of pain in the axial and appendicular musculoskeletal system are performed with increasing frequency. Despite the presence of evidence-based guidelines for such procedures, there are wide variations in practice. Case reports of serious complications such as spinal cord infarction or infection from spine injections lack appropriate context and create a misleading view of the risks of appropriately performed interventional pain procedures.To evaluate adverse event rate for interventional spine procedures performed at three academic interventional spine practices.Quality assurance databases at three academic interventional pain management practices that utilize evidence-based guidelines [1] were interrogated for immediate complications from interventional pain procedures. Review of the electronic medical record verified or refuted the occurrence of a complication. Same-day emergency department transfers or visits were also identified by a records search.Immediate complication data were available for 26,061 consecutive procedures. A radiology practice performed 19,170 epidural steroid (primarily transforaminal), facet, sacroiliac, and trigger point injections (2006-2013). A physiatry practice performed 6,190 spine interventions (2004-2009). A second physiatry practice performed 701 spine procedures (2009-2010). There were no major complications (permanent neurologic deficit or clinically significant bleeding [e.g., epidural hematoma]) with any procedure. Overall complication rate was 1.9% (493/26,061). Vasovagal reactions were the most frequent event (1.1%). Nineteen patients (<0.1%) were transferred to emergency departments for: allergic reactions, chest pain, symptomatic hypertension, and a vasovagal reaction.This study demonstrates that interventional pain procedures are safely performed with extremely low immediate adverse event rates when evidence-based guidelines are observed.

  View details for PubMedID 27084412

• (471) The relationship between body mass index and fluoroscopy time during intra-articular hip injections: a multicenter cohort study. journal of pain Bhave, M., MCCORMICK, Z., Lee, D., Scholten, P., Chu, S., Babu, A., Caldwell, M., Ziegler, C., Ashraf, H., Cara, J., Clark, R., McCormick, K., Gross, C., Ross, B., Press, J., Smuck, M., Cushman, D., WALEGA, D. 2016; 17 (4S): S92-?

  View details for DOI 10.1016/j.jpain.2016.01.448

  View details for PubMedID 28162725

• (466) The impact of body mass index on fluoroscopy time during lumbar epidural steroid injection: a multicenter cohort study. journal of pain Choxi, S., MCCORMICK, Z., Cushman, D., WALEGA, D., Lee, D., Marcolina, A., Press, J., Kennedy, D., Smuck, M. 2016; 17 (4S): S90-S91

  View details for DOI 10.1016/j.jpain.2016.01.443

  View details for PubMedID 28162717

• The Effects of Local Anesthesia Administration on Pain Experience During Interventional Spine Procedures: A Prospective Controlled Trial PAIN MEDICINE Bakshi, R., Berri, H., Kalpakjian, C., Smuck, M. 2016; 17 (3): 488-493

  Abstract

  It has been postulated that local anesthetic administration may be the most painful part of interventional spine procedures. Despite this, there is a lack of evidence supporting the commonly used traditional technique of anesthetic delivery as part of these procedures. This study tested three hypotheses: 1) alternative method of local anesthesia injection is superior to the traditional method; 2) using the traditional method of injection is not superior to using no local anesthetic; and 3) treatment needle size, anesthetic injection technique, and sedation are associated with pain experienced during procedures.Prospective, multicenter clinical trial of 127 participants who underwent elective bilateral symmetric interventional spine procedures in outpatient spine clinics.Primary outcomes were pain scores during and after procedures to examine the influence of anesthetic injection method and treatment needle gauge on pain experience using linear mixed model regression analysis. A post-hoc comparison of estimated marginal mean pain scores was completed on both anesthetic injection method and treatment needle gauge.The alternative method was superior (P < 0.05) to the traditional method on post procedural pain scores. Injecting local anesthetic with the traditional or alternative method was not superior to using no local anesthetic. Treatment needle size, pain at one inch of treatment needle insertion, and baseline pain were all significantly (P < 0.05) associated with overall procedural pain. Further studies are needed optimize and justify local anesthetic injections for these procedures.

  View details for DOI 10.1093/pm/pnv015

  View details for Web of Science ID 000373731300007

• The Effects of Local Anesthesia Administration on Pain Experience During Interventional Spine Procedures: A Prospective Controlled Trial. Pain medicine (Malden, Mass.) Bakshi, R., Berri, H., Kalpakjian, C., Smuck, M. 2016; 17 (3): 488-493

  Abstract

  It has been postulated that local anesthetic administration may be the most painful part of interventional spine procedures. Despite this, there is a lack of evidence supporting the commonly used traditional technique of anesthetic delivery as part of these procedures. This study tested three hypotheses: 1) alternative method of local anesthesia injection is superior to the traditional method; 2) using the traditional method of injection is not superior to using no local anesthetic; and 3) treatment needle size, anesthetic injection technique, and sedation are associated with pain experienced during procedures.Prospective, multicenter clinical trial of 127 participants who underwent elective bilateral symmetric interventional spine procedures in outpatient spine clinics.Primary outcomes were pain scores during and after procedures to examine the influence of anesthetic injection method and treatment needle gauge on pain experience using linear mixed model regression analysis. A post-hoc comparison of estimated marginal mean pain scores was completed on both anesthetic injection method and treatment needle gauge.The alternative method was superior (P < 0.05) to the traditional method on post procedural pain scores. Injecting local anesthetic with the traditional or alternative method was not superior to using no local anesthetic. Treatment needle size, pain at one inch of treatment needle insertion, and baseline pain were all significantly (P < 0.05) associated with overall procedural pain. Further studies are needed optimize and justify local anesthetic injections for these procedures.

  View details for DOI 10.1093/pm/pnv015

  View details for PubMedID 26814251

• Adverse Event Rates Associated with Transforaminal and Interlaminar Epidural Steroid Injections: A Multi-Institutional Study PAIN MEDICINE El-Yahchouchi, C. A., Plastaras, C. T., Maus, T. P., Carr, C. M., McCormick, Z. L., Geske, J. R., Smuck, M., Pingree, M. J., Kennedy, D. J. 2016; 17 (2): 239-249

  Abstract

  Transforaminal epidural steroid injections (TFESI) have demonstrated efficacy and effectiveness in treatment of radicular pain. Despite little evidence of efficacy/effectiveness, interlaminar epidural steroid injections (ILESI) are advocated by some as primary therapy for radicular pain due to purported greater safety.To assess immediate and delayed adverse event rates of TFESI and ILESI injections at three academic medical centers utilizing International Spine Intervention Society practice guidelines.Quality assurance databases from a Radiology and two physical medicine and rehabilitation (PM&R) practices were interrogated. Medical records were reviewed, verifying immediate and delayed adverse events.There were no immediate major adverse events of neurologic injury or hemorrhage in 16,638 consecutive procedures in all spine segments (14,956 TFESI; 1,682 ILESI). Vasovagal reactions occurred in 1.2% of procedures, more frequently (P = 0.004) in TFESI (1.3%) than ILESI (0.5%). Dural punctures occurred in 0.06% of procedures, more commonly after ILESI (0.2% vs 0.04%, P = 0.006). Delayed follow up on PM&R patients (92.5% and 78.5, next business day) and radiology patients (63.1%, 2 weeks) identified no major adverse events of neurologic injury, hemorrhage, or infection. There were no significant differences in delayed minor adverse event rates. Central steroid response (sleeplessness, flushing, nonpositional headache) was seen in 2.6% of both TFESI and ILESI patients. 2.1% of TFESI and 1.8% of ILESI patients reported increased pain. No long-term sequelae were seen from any immediate or delayed minor adverse event.Both transforaminal and ILESI are safely performed with low immediate and delayed adverse event rates when informed by evidence-based procedural guidelines. By demonstrating comparable safety, this study suggests that the choice between ILESI and TFESIs can be based on documented efficacy and effectiveness and not driven by safety concerns.

  View details for DOI 10.1111/pme.12896

  View details for Web of Science ID 000373731000012

  View details for PubMedID 26593277

• Response to Letter by Dr. Lipetz PAIN MEDICINE Kennedy, D. J., Schneider, B., Smuck, M., Plastaras, C. T. 2016; 17 (1): 190–91

  View details for DOI 10.1111/pme.12879

  View details for Web of Science ID 000373730500022

  View details for PubMedID 26272826

• [18F]FDG PET/MRI of patients with chronic pain alters management: early experience. EJNMMI physics Biswal, S., Behera, D., Yoon, D. H., Holley, D., Ith, M. A., Carroll, I., Smuck, M., Hargreaves, B. 2015; 2: A84-?

  View details for DOI 10.1186/2197-7364-2-S1-A84

  View details for PubMedID 26956346

  View details for PubMedCentralID PMC4798651

• Differential Rates of Inadvertent Intravascular Injection during Lumbar Transforaminal Epidural Injections Using Blunt-Tip, Pencil-Point, and Catheter-Extension Needles PAIN MEDICINE Smuck, M., Paulus, S., Patel, A., Demirjian, R., Ith, M. A., Kennedy, D. J. 2015; 16 (11): 2084-2089

  Abstract

  To quantify the incidence of inadvertent vascular penetration during lumbosacral transforaminal epidural injections using blunt-tip, pencil-point, and catheter-extension needles.This is a prospective, observational, consecutive cohort study.Two hundred consecutive patients undergoing lumbosacral transforaminal epidural injections at an academic outpatient spine center.Four hundred seventy-five fluoroscopically guided lumbosacral transforaminal epidural injections were performed on consecutively consenting patients by one interventional spine physician, using three different needle types. The presence or absence of vascular uptake was determined during contrast injection under live fluoroscopy.Vascular uptake of contrast was observed in 58 of the total 475 injections, for an overall incidence of 12.2%. By needle type, the incidence of inadvertent vascular uptake was 16.6% (26/157) in the pencil-point group, 15.6% (24/154) in the blunt-tip group, and 4.9% (8/164) in the catheter-extension group. The difference in rates is statistically significant between the catheter-extension needle group and both the pencil-point group (P = 0.0009) and blunt-tip group (P = 0.0024). A secondary analysis was performed to quantify the incidence of functional pitfalls between needle groups, with a significantly lower incidence in the pencil-point group compared to both the catheter-extension (P = 0.0148) and blunt-tip needle (P = 0.0288) groups.Blunt-tip and pencil-point needles have comparable risk of inadvertent vascular injection during lumbosacral transforaminal injections. Catheter-extension needles demonstrated a reduce incidence of vascular uptake, but also result in a significantly higher rate of functional pitfalls that limits their usefulness in routine practice.

  View details for Web of Science ID 000368296600005

• Differential Rates of Inadvertent Intravascular Injection during Lumbar Transforaminal Epidural Injections Using Blunt-Tip, Pencil-Point, and Catheter-Extension Needles. Pain medicine (Malden, Mass.) Smuck, M., Paulus, S., Patel, A., Demirjian, R., Ith, M. A., Kennedy, D. J. 2015; 16 (11): 2084-9

  Abstract

  To quantify the incidence of inadvertent vascular penetration during lumbosacral transforaminal epidural injections using blunt-tip, pencil-point, and catheter-extension needles.This is a prospective, observational, consecutive cohort study.Two hundred consecutive patients undergoing lumbosacral transforaminal epidural injections at an academic outpatient spine center.Four hundred seventy-five fluoroscopically guided lumbosacral transforaminal epidural injections were performed on consecutively consenting patients by one interventional spine physician, using three different needle types. The presence or absence of vascular uptake was determined during contrast injection under live fluoroscopy.Vascular uptake of contrast was observed in 58 of the total 475 injections, for an overall incidence of 12.2%. By needle type, the incidence of inadvertent vascular uptake was 16.6% (26/157) in the pencil-point group, 15.6% (24/154) in the blunt-tip group, and 4.9% (8/164) in the catheter-extension group. The difference in rates is statistically significant between the catheter-extension needle group and both the pencil-point group (P = 0.0009) and blunt-tip group (P = 0.0024). A secondary analysis was performed to quantify the incidence of functional pitfalls between needle groups, with a significantly lower incidence in the pencil-point group compared to both the catheter-extension (P = 0.0148) and blunt-tip needle (P = 0.0288) groups.Blunt-tip and pencil-point needles have comparable risk of inadvertent vascular injection during lumbosacral transforaminal injections. Catheter-extension needles demonstrated a reduce incidence of vascular uptake, but also result in a significantly higher rate of functional pitfalls that limits their usefulness in routine practice.

  View details for DOI 10.1111/pme.12861

  View details for PubMedID 26442619

• A proposed set of metrics for standardized outcome reporting in the management of low back pain. Acta orthopaedica Clement, R. C., Welander, A., Stowell, C., Cha, T. D., Chen, J. L., Davies, M., Fairbank, J. C., Foley, K. T., Gehrchen, M., Hagg, O., Jacobs, W. C., Kahler, R., Khan, S. N., Lieberman, I. H., Morisson, B., Ohnmeiss, D. D., Peul, W. C., Shonnard, N. H., Smuck, M. W., Solberg, T. K., Stromqvist, B. H., Hooff, M. L., Wasan, A. D., Willems, P. C., Yeo, W., Fritzell, P. 2015; 86 (5): 523-533

  Abstract

  Background and purpose - Outcome measurement has been shown to improve performance in several fields of healthcare. This understanding has driven a growing interest in value-based healthcare, where value is defined as outcomes achieved per money spent. While low back pain (LBP) constitutes an enormous burden of disease, no universal set of metrics has yet been accepted to measure and compare outcomes. Here, we aim to define such a set. Patients and methods - An international group of 22 specialists in several disciplines of spine care was assembled to review literature and select LBP outcome metrics through a 6-round modified Delphi process. The scope of the outcome set was degenerative lumbar conditions. Results - Patient-reported metrics include numerical pain scales, lumbar-related function using the Oswestry disability index, health-related quality of life using the EQ-5D-3L questionnaire, and questions assessing work status and analgesic use. Specific common and serious complications are included. Recommended follow-up intervals include 6, 12, and 24 months after initiating treatment, with optional follow-up at 3 months and 5 years. Metrics for risk stratification are selected based on pre-existing tools. Interpretation - The outcome measures recommended here are structured around specific etiologies of LBP, span a patient's entire cycle of care, and allow for risk adjustment. Thus, when implemented, this set can be expected to facilitate meaningful comparisons and ultimately provide a continuous feedback loop, enabling ongoing improvements in quality of care. Much work lies ahead in implementation, revision, and validation of this set, but it is an essential first step toward establishing a community of LBP providers focused on maximizing the value of the care we deliver.

  View details for DOI 10.3109/17453674.2015.1036696

  View details for PubMedID 25828191

• Morphologic changes in the lumbar spine after lumbar medial branch radiofrequency neurotomy: a quantitative radiological study SPINE JOURNAL Smuck, M., Crisostomo, R. A., Demirjian, R., Fitch, D. S., Kennedy, D. J., Geisser, M. E. 2015; 15 (6): 1415-1421

  Abstract

  Medial branch radiofrequency neurotomy (RFN) is a common treatment for zygapophyseal joint pain. The lumbar medial branch innervates these joints and adjacent structures. The impact of the intended neurotomy on these structures remains unclear. No studies have yet verified quantitatively the effect of medial branch RFN on intervertebral discs, facet joints, and multifidus cross-sectional area.The aim of this study was to determine, using objective radiographic measures, whether there is a quantitative difference in the lumbar multifidus muscle cross-sectional area, facet joint degeneration, or intervertebral disc degeneration after segmental medial branch RFN.This is a retrospective single-cohort study performed at a university spine center.The patient sample consisted of 27 patients treated with lumbar medial branch RFN, with pre- and posttreatment magnetic resonance images available for analysis.The primary study outcome measure was interval change in fat-subtracted multifidus cross-sectional area, and intervertebral disc and zygapophyseal joint degeneration grade.In this retrospective study, segmental levels unaffected by RFN treatment were used as controls to compare against levels affected by treatment.Levels affected by RFN demonstrated a significantly greater amount of disc degeneration compared with unaffected levels (14.9% vs. 4.6%; p=.0489). There was no statistical difference in the multifidus cross-sectional area or rates of deterioration in the zygapophyseal joints observed.The full impact of RFN on multifidus function, morphology, and segmental anatomy is unknown. This retrospective study indicates that measurable changes in segmental morphology may occur after lumbar medial branch RFN. These findings require validation in a prospective, controlled study.

  View details for DOI 10.1016/j.spinee.2013.06.096

  View details for Web of Science ID 000354875700043

  View details for PubMedID 24239488

• The Use of Moderate Sedation for the Secondary Prevention of Adverse Vasovagal Reactions PAIN MEDICINE Kennedy, D. J., Schneider, B., Smuck, M., Plastaras, C. T. 2015; 16 (4): 673-679

  Abstract

  Vasovagal reactions can occur with spine procedures and may result in premature procedure termination or other adverse events.To evaluate if moderate sedation is an effective means of secondary prevention for vasovagal reactions.Prospectively collected data on 6,364 consecutive spine injections.Of the 6,364 spine injections, 6,150 spine injections were done without moderate sedation and resulted in 205 vasovagal reactions (3.3% [95% confidence interval {CI} 2.9-3.8%]). One hundred thirty-four spine procedures were performed on patients that had a history of prior vasovagal reaction during a spine procedure. Of these, 90 procedures were performed without moderate sedation, and 21/90 (23.3% [95% CI 15.2-32.1%]) were complicated by a repeat vasovagal reaction. None of 44 repeat injections that utilized moderate sedation experienced a repeat vasovagal reaction (0% [95% CI 0-9.6%]) (χ(2)  = 12.17, P < 0.00048). The rate of vasovagal reaction in patients with a history of prior reaction undergoing repeat injection without conscious sedation was significantly higher (23.3% [95% CI 15.2-32.1%]) than the rate in patients with no such history (3.0% [95% CI 2.6-3.5%] [χ(2)  = 113.4, P < 1.78E-26]).A history of vasovagal reaction is a strong predictor of experiencing a vasovagal reaction on subsequent procedures. No vasovagal reactions occurred with the use of moderate sedation, including in the 44 injections in patients that had a history of vasovagal reaction during spine procedures. The overall low rate of vasovagal reactions is low, and greater benefits of moderate sedation were observed when utilized as secondary prevention of repeat vasovagal reactions.

  View details for DOI 10.1111/pme.12632

  View details for Web of Science ID 000352617600009

  View details for PubMedID 25529469

• Determinants of Physical Activity in America: A First Characterization of Physical Activity Profile Using the National Health and Nutrition Examination Survey (NHANES) PM&R Kao, M. J., Jarosz, R., Goldin, M., Patel, A., Smuck, M. 2014; 6 (10): 882-892

  Abstract

  To develop and implement methodologies for characterizing accelerometry-derived patterns of physical activity (PA) in the United States in relation to demographics, anthropometrics, behaviors, and comorbidities using the National Health and Nutrition Examination Survey (NHANES) dataset.Retrospective analysis of nationally representative database.Computer-generated modeling in silico.A total of 6329 adults in the United States from the NHANES 2003-2004 database.To discover subtle multivariate signal in the dynamic and noisy accelerometry data, we developed a novel approach, termed discretized multiple adaptive regression and implemented the algorithm in SAS 9.2 (SAS Institute, Cary, NC).Demographic, anthropometric, comorbidity, and behavioral variables.The intensity of PA decreased with both increased age and increased body mass index. Both greater education and greater income correlate with increased activity over short durations and reduced activity intensity over long durations. Numerous predictors demonstrated effects within activity ranges that may be masked by use of the standard activity intensity intervals. These include age, one of the most robust variables, where we discovered decreasing activities inside the moderate activity range. It also includes gender, where women compared with men have increased proportions of active times up to the center of light activity range, and income greater than $45,000, where a complex effect is seen with little correspondence to existing cut-points.The results presented in this study suggest that the method of multiple regression and heat map visualization can generate insights otherwise hidden in large datasets such as NHANES. A review of the provided heat maps reveals the trends discussed previously involving demographic, anthropometric, comorbidity, and behavioral variables. It also demonstrates the power of accelerometry to expose alterations in PA. Ultimately, this study provides a US population-based norm to use in future studies of PA.

  View details for DOI 10.1016/j.pmrj.2014.03.004

  View details for Web of Science ID 000344234600004

• Trainee involvement in transforaminal epidural steroid injections associated with increased incidence of vasovagal reactions. PM & R : the journal of injury, function, and rehabilitation Schneider, B., Kennedy, D. J., Casey, E., Smuck, M., Conrad, B., Plastaras, C. 2014; 6 (10): 914-919

  Abstract

  To evaluate whether trainee involvement (resident and fellow) during transforaminal epidural steroid injections (TFESI) results in greater rates of vasovagal reactions.Retrospective study on consecutive patients.Single academic medical center with multiple attending physicians and trainees.A total of 2642 consecutive subjects undergoing 4482 TFESI were analyzed from March 8, 2004, to January 30, 2009.The Pearson χ(2) test was used to determine the relationship between vasovagal reactions and level of trainee involvement.A total of 4482 TFESIs were performed, with 157 (3.5%) of procedures complicated by a vasovagal reaction. An attending physician performed 2884 (64.3%) procedures without trainee involvement, with only 79 (2.7%) vasovagal reaction noted. A fellow was involved in 723 (16.1%) procedures, with 30 (4.1%) noted to have a vasovagal reaction. A resident was involved in 875 (19.5%) procedures, with 48 (5.5%) having a vasovagal reaction. Overall, trainees were involved in 1598 (35.7%) cases, of which 78 (4.9%) were complicated by vasovagal reaction. When a trainee was involved in the case, there was a greater incidence of vasovagal episodes (P < .001, χ(2) = 16.047). Although there was a trend towards greater vasovagal rates with residents over fellows, this did not reach statistical difference.Vasovagal reactions can occur with spine injection procedures and may result in premature procedure termination or other adverse events. Although this retrospective study has significant potential for bias, it appears that trainee involvement in a TFESI is associated with a greater incidence of vasovagal reaction (P < .001, χ(2) = 16.047).

  View details for DOI 10.1016/j.pmrj.2014.04.003

  View details for PubMedID 24755514

• 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 PubMedID 25186460

• Trainee Involvement in Transforaminal Epidural Steroid Injections Associated With Increased Incidence of Vasovagal Reactions PM&R Schneider, B., Kennedy, D. J., Casey, E., Smuck, M., Conrad, B. 2014; 6 (10): 914-919

  Abstract

  To evaluate whether trainee involvement (resident and fellow) during transforaminal epidural steroid injections (TFESI) results in greater rates of vasovagal reactions.Retrospective study on consecutive patients.Single academic medical center with multiple attending physicians and trainees.A total of 2642 consecutive subjects undergoing 4482 TFESI were analyzed from March 8, 2004, to January 30, 2009.The Pearson χ(2) test was used to determine the relationship between vasovagal reactions and level of trainee involvement.A total of 4482 TFESIs were performed, with 157 (3.5%) of procedures complicated by a vasovagal reaction. An attending physician performed 2884 (64.3%) procedures without trainee involvement, with only 79 (2.7%) vasovagal reaction noted. A fellow was involved in 723 (16.1%) procedures, with 30 (4.1%) noted to have a vasovagal reaction. A resident was involved in 875 (19.5%) procedures, with 48 (5.5%) having a vasovagal reaction. Overall, trainees were involved in 1598 (35.7%) cases, of which 78 (4.9%) were complicated by vasovagal reaction. When a trainee was involved in the case, there was a greater incidence of vasovagal episodes (P < .001, χ(2) = 16.047). Although there was a trend towards greater vasovagal rates with residents over fellows, this did not reach statistical difference.Vasovagal reactions can occur with spine injection procedures and may result in premature procedure termination or other adverse events. Although this retrospective study has significant potential for bias, it appears that trainee involvement in a TFESI is associated with a greater incidence of vasovagal reaction (P < .001, χ(2) = 16.047).

  View details for DOI 10.1016/j.pmrj.2014.04.003

  View details for Web of Science ID 000344234600008

• 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

• A Randomized Trial of Epidural Glucocorticoid Injections for Spinal Stenosis NEW ENGLAND JOURNAL OF MEDICINE Friedly, J. L., Comstock, B. A., Turner, J. A., Heagerty, P. J., Deyo, R. A., Sullivan, S. D., Bauer, Z., Bresnahan, B. W., Avins, A. L., Nedeljkovic, S. S., Nerenz, D. R., Standaert, C., Kessler, L., Akuthota, V., Annaswamy, T., Chen, A., Diehn, F., Firtch, W., Gerges, F. J., Gilligan, C., Goldberg, H., Kennedy, D. J., Mandel, S., Tyburski, M., Sanders, W., Sibell, D., Smuck, M., Wasan, A., Won, L., Jarvik, J. G. 2014; 371 (1): 11-21

  Abstract

  Epidural glucocorticoid injections are widely used to treat symptoms of lumbar spinal stenosis, a common cause of pain and disability in older adults. However, rigorous data are lacking regarding the effectiveness and safety of these injections.In a double-blind, multisite trial, we randomly assigned 400 patients who had lumbar central spinal stenosis and moderate-to-severe leg pain and disability to receive epidural injections of glucocorticoids plus lidocaine or lidocaine alone. The patients received one or two injections before the primary outcome evaluation, performed 6 weeks after randomization and the first injection. The primary outcomes were the score on the Roland-Morris Disability Questionnaire (RMDQ, in which scores range from 0 to 24, with higher scores indicating greater physical disability) and the rating of the intensity of leg pain (on a scale from 0 to 10, with 0 indicating no pain and 10 indicating "pain as bad as you can imagine").At 6 weeks, there were no significant between-group differences in the RMDQ score (adjusted difference in the average treatment effect between the glucocorticoid-lidocaine group and the lidocaine-alone group, -1.0 points; 95% confidence interval [CI], -2.1 to 0.1; P=0.07) or the intensity of leg pain (adjusted difference in the average treatment effect, -0.2 points; 95% CI, -0.8 to 0.4; P=0.48). A prespecified secondary subgroup analysis with stratification according to type of injection (interlaminar vs. transforaminal) likewise showed no significant differences at 6 weeks.In the treatment of lumbar spinal stenosis, epidural injection of glucocorticoids plus lidocaine offered minimal or no short-term benefit as compared with epidural injection of lidocaine alone. (Funded by the Agency for Healthcare Research and Quality; ClinicalTrials.gov number, NCT01238536.).

  View details for DOI 10.1056/NEJMoa1313265

  View details for Web of Science ID 000338265700005

• Trends in ambulatory physician opioid prescription in the United States, 1997-2009. PM & R : the journal of injury, function, and rehabilitation Jeffrey Kao, M., Minh, L. C., Huang, G. Y., Mitra, R., Smuck, M. 2014; 6 (7): 575-582 e4

  Abstract

  To describe the changing practice pattern of opioid medication prescription by health care providers and its relationship to shifts in the incidence of back pain, demographics, and health care access.Retrospective analysis of nationally representative databases.In silico.Patients who presented at a set of randomly selected health care facilities on the days of data collection.Nationally representative surveys from the Centers for Disease Control and Prevention (National Hospital and Ambulatory Medical Center Survey and National Ambulatory Medical Center Survey) were investigated for 3 ambulatory settings-emergency department (ED), primary care physician (PCP), and specialist physician offices-between the years 1997 and 2009. Diagnoses, prescription medications, insurance source, and demographics were determined. Weighted logistic regression modeling with the SAS program (SAS Institute, Cary, NC) was used to estimate 5-year odds ratios (ORs) and covariate effects.Diagnoses, prescription medications, insurance source, and demographics were measured. The relationships between opioid medication prescription and (1) the chief complaint and (2) back pain diagnoses were studied. Domain analysis was used to properly account for the stochasticity introduced by subset analyses.From 1997 to 2009, increasing all-diagnosis opioid prescription was accompanied by significant shifts in patient demographics and insurance access. For all-diagnosis opioid prescription, after we adjusted for age, gender, race, and insurance source, the increase persisted at a 5-year OR of 1.33, 1.29, and 1.53 for ED, PCP clinics, and specialist clinics (95% confidence interval 1.26-1.41, 1.19-1.40, and 1.37-1.69), respectively. The increasing prevalence of back pain diagnosis was eclipsed by increasing opioid prescriptions, estimated at 5-year ORs of 1.35, 1.38, and 1.75 for ED, PCP clinics, and specialist clinics (95% confidence interval 1.22-1.48, 1.19-1.61, 1.40-2.19), respectively.In the United States, from 1997-2009, (1) variable increases in opioid prescription across ambulatory care settings were not accounted for by changing demographics and health care access; (2) significant disparities existed in opioid prescription as a function of age, gender, race/ethnicity, and payer source; and (3) for back pain, increasing opioid prescription was not accounted for by changing incidence.

  View details for DOI 10.1016/j.pmrj.2013.12.015

  View details for PubMedID 24412267

• Reply to letter to the editor "Morphologic changes in the lumbar spine following lumbar medial branch radiofrequency neurotomy: a quantitative radiologic study". spine journal Smuck, M., Crisostomo, R. A., Demirjian, R., Fitch, D. S., Kennedy, D. J., Geisser, M. E. 2014; 14 (6): 1089-1090

  View details for DOI 10.1016/j.spinee.2014.02.001

  View details for PubMedID 24851740

• Assessment and management of back pain. JAMA internal medicine Kao, M., Zheng, P., Smuck, M. 2014; 174 (3): 479-?

  View details for DOI 10.1001/jamainternmed.2013.13695

  View details for PubMedID 24590093

• Does physical activity influence the relationship between low back pain and obesity? SPINE JOURNAL Smuck, M., Kao, M. J., Brar, N., Martinez-Ith, A., Choi, J., Tomkins-Lane, C. C. 2014; 14 (2): 209-216

  Abstract

  Evidence supporting an association between obesity and low back pain (LBP) continues to grow; yet little is known about the cause and effect of this relationship. Even less is known about the mechanisms linking the two. Physical activity is a logical suspect, but no study has demonstrated its role.This study was designed to examine the interrelationship between physical activity, obesity, and LBP. The specific aims were to determine if obesity is a risk factor for LBP in the U.S. population, measure the strength of any observed association, and evaluate the role of physical activity in modulating this association.A cross-sectional U.S. population-based study.A cohort of 6,796 adults from the 2003-2004 National Health and Nutrition Examination Survey.Demographic information, an in-depth health questionnaire, physical examination details, and 7-day free-living physical activity monitoring using accelerometry (ActiGraph AM-7164; ActiGraph, Pensacola, FL, USA).LBP status was determined by questionnaire response. Body mass index (BMI) was calculated during physical examination and divided here into four groups (normal weight <25, overweight 25-30, obese 31-35, and ultraobese 36+). Summary measures of physical activity were computed based on intensity cutoffs, percentile intensities, and bout. Demographics, social history, and comorbid health conditions were used to build adjusted weighted logistic regression models constructed using Akaike Information Criterion. All displayed estimates are significant at level <.05. No external funding was received to support this study. None of the authors report conflicts of interest directly related to the specific subject matter of this manuscript.In the U.S. population, the risk of low LBP increases in step with BMI from 2.9% for normal BMI (20-25) to 5.2% for overweight (26-30), 7.7% for obese (31-35), and 11.6% for ultraobese (36+). Smoking is consistently the strongest predictor of LBP across the BMI spectrum (odds ratio 1.6-2.9). Physical activity also modulates these risks. In the overall model, the best physical activity predictors of LBP are in the moderate and high intensity ranges with small effects (odds ratio 0.98 and 0.996 per standard deviation increase, respectively). When broken down by BMI, time spent in sedentary and moderate activity ranges demonstrate more robust influences on LBP status in the overweight, obese, and ultraobese groups.Increased BMI is a risk factor for back pain in Americans. More important, the role of physical activity in mitigating back pain risk is shown to be of greater consequence in the overweight and obese populations.

  View details for DOI 10.1016/j.spinee.2013.11.010

  View details for Web of Science ID 000329971900004

  View details for PubMedID 24239800

• Sports Medicine: Study Guide and Review for Boards. American journal of physical medicine & rehabilitation Burns, M., Smuck, M. 2014

  View details for PubMedID 24398581

• 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

• Does the presence of the fibronectin-aggrecan complex predict outcomes from lumbar discectomy for disc herniation? The spine journal : official journal of the North American Spine Society Smith, M. W., Ith, A., Carragee, E. J., Cheng, I., Alamin, T. F., Golish, S. R., Mitsunaga, K., Scuderi, G. J., Smuck, M. 2013

  Abstract

  Protein biomarkers associated with lumbar disc disease have been studied as diagnostic indicators and therapeutic targets. Recently, a cartilage degradation product, the fibronectin-aggrecan complex (FAC) identified in the epidural space, has been shown to predict response to lumbar epidural steroid injection in patients with radiculopathy from herniated nucleus pulposus (HNP).Determine the ability of FAC to predict response to microdiscectomy for patients with radiculopathy due to lumbar disc herniation STUDY DESIGN/SETTING: Single-center prospective consecutive cohort study.Patients with radiculopathy from HNP with concordant symptoms to MRI who underwent microdiscectomy.Oswestry disability index (ODI) and visual analog scores (VAS) were noted at baseline and at 3-month follow-up. Primary outcome of clinical improvement was defined as patients with both a decrease in VAS of at least 3 points and ODI >20 points.Intraoperative sampling was done via lavage of the excised fragment by ELISA for presence of FAC. Funding for the ELISA was provided by Cytonics, Inc.Seventy-five patients had full complement of data and were included in this analysis. At 3-month follow-up, 57 (76%) patents were "better." There was a statistically significant association of the presence of FAC and clinical improvement (p=.017) with an 85% positive predictive value. Receiver-operating-characteristic (ROC) curve plotting association of FAC and clinical improvement demonstrates an area under the curve (AUC) of 0.66±0.08 (p=.037). Subset analysis of those with weakness on physical examination (n=48) plotting the association of FAC and improvement shows AUC on ROC of 0.81±0.067 (p=.002).Patients who are "FAC+" are more likely to demonstrate clinical improvement following microdiscectomy. The data suggest that the inflammatory milieu plays a significant role regarding improvement in patients undergoing discectomy for radiculopathy in lumbar HNP, even in those with preoperative weakness. The FAC represents a potential target for treatment in HNP.

  View details for DOI 10.1016/j.spinee.2013.06.064

  View details for PubMedID 24239034

• Duration of fluoroscopic-guided spine interventions and radiation exposure is increased in overweight patients. PM & R : the journal of injury, function, and rehabilitation Smuck, M., Zheng, P., Chong, T., Kao, M., Geisser, M. E. 2013; 5 (4): 291-296

  Abstract

  The impact of patient body mass index (BMI) on image-guided spine interventions remains unknown. Higher BMI is known to complicate the acquisition of radiographic images. Therefore it can be hypothesized that the patient's body habitus can influence the delivery of a spinal injection.To quantify the impact of patient BMI on the length of fluoroscopy and procedure times during spine interventions.Secondary analysis of 2 prospective observational studies.All injections were performed in an outpatient university setting.A total of 209 patients in whom spine injections were performed (99 women), with a mean age of 54.6 years.The fluoroscopy times for 202 participants and total procedure times for 137 participants were recorded. Additional participant characteristics, including age, gender, BMI, and actual procedures performed, also were collected. Analysis of covariance and linear and nonlinear model analysis were performed to assess the effect of BMI on fluoroscopy and procedure times.Fluoroscopy time and procedure duration times.Participants had a mean age of 54.6 years, 51% were men, and 77% (n = 155) were overweight (BMI ≥25). Participants received the following interventions: 40 zygapophyseal joint injections, 33 medial branch nerve blocks, 113 transforaminal epidural injections, and 16 combined zygapophyseal joint injections and epidural injections. Gender, procedure number, and procedure type did not differ between groups. The overweight group demonstrated a 30% increase in mean fluoroscopy time and a 35% increase in mean procedure time. Controlling for other variables, we found that differences in fluoroscopy time and procedure time were significant (P = .032 and P = .031, respectively) between the 2 groups.Significantly prolonged procedure time and fluoroscopy time in overweight patients increase the risks associated with spine interventions, not only to the patients but also to the operating room staff exposed to ionizing radiation.

  View details for DOI 10.1016/j.pmrj.2013.01.015

  View details for PubMedID 23435199

• Correlation of Paraspinal Atrophy and Denervation in Back Pain and Spinal Stenosis Relative to Asymptomatic Controls PM&R Yarjanian, J. A., Fetzer, A., Yamakawa, K. S., Tong, H. C., Smuck, M., Haig, A. 2013; 5 (1): 39-44

  Abstract

  To determine the relationship among spinal stenosis, back pain, paraspinal muscle denervation, and paraspinal muscle atrophy.A prospective masked, double-controlled study.A university hospital and outpatient spine clinic.Ten asymptomatic subjects, 10 subjects with mechanical low back pain, and 15 subjects with symptomatic spinal stenosis; age range, 55-80 years old.Magnetic resonance imaging measurements of minimum spinal canal diameter, paraspinal muscle cross-sectional area at the level of the L5-S1 disk, and quantified paraspinal electrodiagnostic testing (MiniPM) were performed by examiners blinded to each other's results and to the participants' clinical information.Paraspinal muscle cross-sectional area and MiniPM scores.A paraspinal cross-sectional area decreased significantly from asymptomatic subjects (3872 mm(2)) to subjects with low back pain (3627 mm(2)) and to subjects with spinal stenosis (2985 mm(2)). In the stenosis group, there was a trend toward increased paraspinal denervation in the subjects with severe spinal stenosis, but this was not statistically significant.Symptomatic spinal stenosis results in greater paraspinal muscle atrophy than low back pain alone. The extent of paraspinal atrophy was not significantly explained by the extent of denervation, thus, it may be reversible, and the role of paraspinal muscle rehabilitation in patients with spinal stenosis deserves further study.

  View details for DOI 10.1016/j.pmrj.2012.08.017

  View details for Web of Science ID 000314614700007

  View details for PubMedID 23332908

• Cervical Foraminal Versus Interlaminar Epidurals: Risks, Benefits, and Alternatives. Curr Phys Med Rehabil Rep. 2013 June;1(2) Smuck, M., Demirjian, R., Kennedy, D. J. 2013; 1 (2): 125-134
• Commentary: More or less satisfied? SPINE JOURNAL Smuck, M. 2012; 12 (12): 1140-1141

  Abstract

  COMMENTARY ON: Hazard RG, Spratt KF, McDonough CM, et al. Patient-centered evaluation of outcomes from rehabilitation for chronic disabling spinal disorders: the impact of personal goal achievement on patient satisfaction. Spine J 2012;12:1132-7 (in this issue).

  View details for DOI 10.1016/j.spinee.2012.09.004

  View details for Web of Science ID 000313694300012

  View details for PubMedID 23312141

• Functional assessment of the acute local and distal transplantation of human neural stem cells after spinal cord injury SPINE JOURNAL Cheng, I., Mayle, R. E., Cox, C. A., Park, D. Y., Smith, R. L., Corcoran-Schwartz, I., Ponnusamy, K. E., Oshtory, R., Smuck, M. W., Mitra, R., Kharazi, A. I., Carragee, E. J. 2012; 12 (11): 1040-1044

  Abstract

  Spinal cord injury can lead to severe functional impairments secondary to axonal damage, neuronal loss, and demyelination. The injured spinal cord has limited regrowth of damaged axons. Treatment remains controversial, given inconsistent functional improvement. Previous studies demonstrated functional recovery of rats with spinal cord contusion after transplantation of rat fetal neural stem cells.We hypothesized that acute transplantation of human fetal neural stem cells (hNSCs) both locally at the injury site as well as distally via intrathecal injection would lead to improved functional recovery compared with controls.Twenty-four adult female Long-Evans hooded rats were randomized into four groups with six animals in each group: two experimental and two control. Functional assessment was measured after injury and then weekly for 6 weeks using the Basso, Beattie, and Bresnahan Locomotor Rating Score. Data were analyzed using two-sample t test and linear mixed-effects model analysis.Posterior exposure and laminectomy at T10 level was used. Moderate spinal cord contusion was induced by the Multicenter Animal Spinal Cord Injury Study Impactor with 10-g weight dropped from a height of 25 mm. Experimental subjects received either a subdural injection of hNSCs locally at the injury site or intrathecal injection of hNSCs through a separate distal laminotomy. Controls received control media injection either locally or distally.Statistically significant functional improvement was observed in local or distal hNSCs subjects versus controls (p=.034 and 0.016, respectively). No significant difference was seen between local or distal hNSC subjects (p=.66).Acute local and distal transplantation of hNSCs into the contused spinal cord led to significant functional recovery in the rat model. No statistical difference was found between the two techniques.

  View details for DOI 10.1016/j.spinee.2012.09.005

  View details for Web of Science ID 000311807300013

  View details for PubMedID 23063425

• Success of Initial and Repeated Medial Branch Neurotomy for Zygapophysial Joint Pain: A Systematic Review PM&R Smuck, M., Crisostomo, R. A., Trivedi, K., Agrawal, D. 2012; 4 (9): 686-692

  Abstract

  To review the duration of pain relief after initial and repeated radiofrequency neurotomy (RFN) for cervical and lumbar zygapophysial joint pain.We searched PubMed to identify all articles that met review criteria for in-depth analysis, synthesis, and review.Data from 16 articles are reported in this review, including 8 cervical studies, 7 lumbar studies, and 1 study of both cervical and lumbar treatment. Overall, methodology and design quality of cervical studies exceeded that of lumbar studies. For initial cervical RFN, average range duration of >50% pain relief was 7.3-8.6 months. Repeated cervical RFN was successful 67%-95% of the time when the first RFN procedure was successful. When the first RFN procedure was unsuccessful, repeated RFN was successful 0%-67% of the time. The average range duration of pain relief after successful repeated RFN was 6.0-12.7 months. For initial lumbar RFN, the average duration of >50% pain relief was 9.0 months. Repeated lumbar RFN was successful 33%-85% of the time when the first RFN procedure was successful. The average duration of pain relief after successful repeated lumbar RFN was 11.6 months.The results of this review indicate that pain relief after initial RFN generally ends after 7-9 months and that repeating RFN is likely to provide additional pain relief if initial RFN was successful. Results are similar between cervical and lumbar spine studies.

  View details for DOI 10.1016/j.pmrj.2012.06.007

  View details for Web of Science ID 000309436500007

  View details for PubMedID 22980421

• Accelerometer-derived Physical Activity And Lower Extremity Functional Changes In Patients Undergoing Spinal Decompression Surgery Buman, M. P., Ith, M., Haskell, W. L., Smuck, M. LIPPINCOTT WILLIAMS & WILKINS. 2012: 805

  View details for Web of Science ID 000310363304262

• Preseason Training for Golfers with Low Back Pain SpineLine Roh EY, G. S. 2012; 13 (1): 17-21
• Sacral Stress Fractures in Athletes SpineLine May/June Watanabe LM, Smuck M, Fredericson M 2012; 13 (3): 19-25
• Orthopaedic Knowledge Update: Spine 4 American Academy of Orthpaedic Surgeons Rao RD, S. 2012: ISBN 978-089203-737-
• Evaluation of the Athlete With Buttock Pain CURRENT SPORTS MEDICINE REPORTS Vasudevan, J. M., Smuck, M., Fredericson, M. 2012; 11 (1): 35-42

  Abstract

  Buttock (gluteal) pain is commonly experienced by athletes of all ages and activity levels. Evaluation of buttock pain can be challenging because the differential diagnoses are extensive. Symptoms may originate from the pelvis or hip or be referred from the lumbosacral spine or neurovascular structures. Few articles in the literature are dedicated to the primary complaint of buttock pain. The purpose of this article is to provide a clinical algorithm to assist the sports clinician in reaching an accurate diagnosis and initiating the appropriate treatment.

  View details for DOI 10.1249/JSR.0b013e3182423d71

  View details for Web of Science ID 000299162200008

  View details for PubMedID 22236824

• Commentary: One small step SPINE JOURNAL Smuck, M., Carragee, E. J. 2011; 11 (9): 824-825

  View details for DOI 10.1016/j.spinee.2011.08.432

  View details for Web of Science ID 000296276100004

  View details for PubMedID 21951609

• Inadvertent Injection of a Cervical Radicular Artery Using an Atraumatic Pencil-Point Needle SPINE Smuck, M., Leung, D. 2011; 36 (3): E220-E223

  Abstract

  Case report and review of the literature.To report the first case of inadvertent injection of a cervical radicular artery using an atraumatic pencil-point needle.Rare complications from cervical transforaminal epidural corticosteroid injection have resulted in infarction of the spinal cord and brain. The most often-hypothesized mechanism is inadvertent intra-arterial injection of particulate corticosteroids with a resulting embolus and infarction.Retrospective review of a patient's history and fluoroscopic imaging.A 30-year-old man with a diagnosed cervical radiculopathy underwent a right C6-C7 transforaminal epidural corticosteroid injection, using a 25-gauge 3.5-inch Whitacre spinal needle. Simultaneous epidural and radicular artery spread were observed under live fluoroscopy. The patient suffered no complications from the procedure.This case demonstrates that the use of pencil-point (Whitacre) needles does not eliminate the risk of inadvertent arterial injection during cervical transforaminal epidurals. Further investigation is required to determine whether the incidence of inadvertent vascular injection is reduced with pencil-point needles compared with sharp-beveled needles.

  View details for DOI 10.1097/BRS.0b013e3181f13417

  View details for Web of Science ID 000286419200022

  View details for PubMedID 21242881

• Vascular causes of radiculopathy: a literature review SPINE JOURNAL Benny, B. V., Nagpal, A. S., Singh, P., Smuck, M. 2011; 11 (1): 73-85

  Abstract

  Vascular etiologies are a significant source of radiculopathy. The entities that are reviewed here include epidural spinal hematoma, subdural spinal hematoma, spinal arteriovenous malformation, vertebral hemangioma, spinal epidural cavernous hemangioma, vertebral artery anomalies (both tortuosity and dissection), aortic aneurysm, hemorrhagic synovial cysts, ligamentum flavum hematoma, and venous varices. The incidence, pathophysiology, typical clinical presentation, appropriate diagnostic workup, and management are summarized.To review and summarize various vascular causes of radiculopathy and how it impacts the management of patients with radicular spinal pain.Literature review.An extensive literature review was done on each of the vascular entities and their presentation as radiculopathy.Vascular etiologies of radiculopathy may be underestimated in the literature. Imaging in addition to the history and physical examination is essential to identifying vascular sources of radiculopathy and establishing correct treatment.In examining patients with radicular pain, extraspinal causes of radiculopathy including vascular entities should be included in the differential. Knowledge of the incidence, pathophysiology, clinical presentation, and management of the possibly underreported various vascular causes of radiculopathy increase the ability of the physician to provide optimal care for the patient. A key aspect to identifying such vascular lesions is appropriate imaging for documenting the source of radiculopathy. Blind injections, done without appropriate imaging for identifying the cause of radiculopathy, and also performed without fluoroscopic guidance, increase not only the risk of misdiagnosis but also the comorbidities associated with spinal injections.

  View details for DOI 10.1016/j.spinee.2010.09.027

  View details for Web of Science ID 000285414600015

  View details for PubMedID 21168101

• Diagnostic Imaging of Painful Lumbar Facet Joints ISPINE: EVIDENCE-BASED INTERVENTIONAL SPINE CARE Smuck, M., Agrawal, D., DePalma, M. J. 2011: 80–89

  View details for Web of Science ID 000289959800009

• Diagnostic Imaging of Painful Lumbar Facet Joints Ispine: Evidence-Based Interventional Spine Care. Demos Smuck M, Agrawal D 2011; 1st ed: 80-89
• 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

• Basic Appearance of Ultrasound Structures and Pitfalls PHYSICAL MEDICINE AND REHABILITATION CLINICS OF NORTH AMERICA McDonald, S., Fredericson, M., Roh, E. Y., Smuck, M. 2010; 21 (3): 461-?

  Abstract

  The role of ultrasound in musculoskeletal imaging is expanding as technology advances and clinicians become better educated about its clinical applications. The main use of musculoskeletal ultrasound to physiatrists is to examine the soft tissues of the body and to diagnose pathologic changes. Ultrasound can be used to assist clinicians in performing interventional procedures. However, to successfully integrate this technology into their clinical practices, physicians must be familiar with the normal and abnormal appearance of tissues. They also must recognize the clinically relevant limitations and pitfalls associated with the use of ultrasound.

  View details for DOI 10.1016/j.pmr.2010.04.002

  View details for PubMedID 20797545

• Considering value SPINE JOURNAL Smuck, M. 2010; 10 (6): 505-506

  View details for DOI 10.1016/j.spinee.2010.04.007

  View details for Web of Science ID 000278797400006

  View details for PubMedID 20494810

• Influence of needle type on the incidence of intravascular injection during transforaminal epidural injections: a comparison of short-bevel and long-bevel needles SPINE JOURNAL Smuck, M., Yu, A. J., Tang, C., Zemper, E. 2010; 10 (5): 367-371

  Abstract

  Vascular penetration and injection of corticosteroids into a vessel during lumbosacral transforaminal epidural injection is a suspected cause of myelopathy. Blunt needles have been suggested to avoid vascular penetration, but they are difficult to navigate. Another alternative to the standard long-bevel sharp needles is the short-bevel needles. Some have postulated that short-bevel needles are the best option for high-risk spine injections because they maintain navigation characteristics while potentially reducing the risk of complications. To date, no studies have been performed to either confirm or refute this.The purpose of this study was to determine if there is a difference in the incidence of vascular penetration during lumbosacral transforaminal epidural injections between short-bevel and long-bevel needles.This is a prospective, observational, in vivo study.The sample comprises patients receiving lumbosacral transforaminal epidural injections at a university-based outpatient spine center.The outcome measure was the incidence of vascular contrast patterns observed under live fluoroscopy.One interventional spine physician recorded contrast patterns observed during 158 fluoroscopically guided lumbosacral transforaminal epidural injections under live fluoroscopy using two different types of needle tips.Vascular injections were observed in 22 of the 158 injections, for an overall incidence of 13.9%. The incidence of vascular injections in the short-bevel group was 15.6% (10/64) and in the long-bevel group was 12.8% (12/94). This difference was not statistically significant (p=.6447). A secondary analysis was performed to determine if the needle gauge influenced the incidence of vascular injections, and again, there were no statistical differences in the overall rates of vascular injection.In comparison with long-bevel needles, short-bevel needles do not reduce the risk of inadvertent vascular injection in lumbosacral transforaminal epidural injections.

  View details for DOI 10.1016/j.spinee.2009.12.018

  View details for Web of Science ID 000278039300003

  View details for PubMedID 20171936

• Plasma disc decompression compared with fluoroscopy-guided transforaminal epidural steroid injections for symptomatic contained lumbar disc herniation: a prospective, randomized, controlled trial Clinical article JOURNAL OF NEUROSURGERY-SPINE Gerszten, P. C., Smuck, M., Rathmell, J. P., Simopoulos, T. T., Bhagia, S. M., Mocek, C. K., Crabtree, T., Bloch, D. A. 2010; 12 (4): 357-371

  Abstract

  Patients with radiculopathy, with or without back pain, often do not respond to conservative care and may be considered for epidural steroid injection therapy or a disc decompression procedure. Plasma disc decompression (PDD) using the Coblation SpineWand device is a percutaneous, minimally invasive interventional procedure. The purpose of this study was to evaluate clinical outcomes with PDD as compared with standard care using fluoroscopy-guided transforaminal epidural steroid injection (TFESI) over the course of 2 years.This was a multicenter randomized controlled clinical study. Ninety patients (18-66 years old) who had sciatica (visual analog scale score > or = 50) associated with a single-level lumbar contained disc herniation were enrolled. In all cases, their condition was refractory to initial conservative care and 1 epidural steroid injection had failed. Participants were randomly assigned to receive either PDD (46 patients) or TFESI (44 patients, up to 2 injections).The patients in the PDD Group had significantly greater reduction in leg pain scores and significantly improved Oswestry Disability Index and 36-Item Short Form Health Survey ([SF-36], physical function, bodily pain, social function, and physical components summary) scores than those in the TFESI Group. During the 2-year follow-up, 25 (56%) of the patients in the PDD Group and 11 (28%) of those in the TFESI Group remained free from having a secondary procedure following the study procedure (log-rank p = 0.02). A significantly higher percentage of patients in the PDD Group showed minimum clinically important change in scores for leg and back pain and SF-36 scores that exceeded literature-based minimum clinically important changes. Procedure-related adverse events, including injection site pain, increased leg or back pain, weakness, and lightheadedness, were observed in 5 patients in the PDD Group (7 events) and 7 in the TFESI Group (14 events).In study patients who had radicular pain associated with a contained lumbar disc herniation, those patients treated with PDD had significantly reduced pain and better quality of life scores than those treated using repeated TFESI. In addition, significantly more PDD patients than TFESI patients avoided having to undergo a secondary procedure during the 2-year study follow-up.

  View details for DOI 10.3171/2009.10.SPINE09208

  View details for Web of Science ID 000275959900005

  View details for PubMedID 20201654

• Adhesive capsulitis: a new management protocol to improve passive range of motion. PM & R : the journal of injury, function, and rehabilitation Mitra, R., Harris, A., Umphrey, C., Smuck, M., Fredericson, M. 2009; 1 (12): 1064-1068

  Abstract

  To examine the short-term efficacy of a nonoperative shoulder protocol for the treatment of adhesive capsulitis.A retrospective chart review was used to collect data for a 3-year period.Academic tertiary medical center.28 consecutive patients diagnosed as having adhesive capsulitis were identified and managed with a new protocol.The protocol consisted of the administration of a suprascapular nerve block, the subsequent injection of an intra-articular steroid, and then the injection of an anesthetic agent with brisement normal saline volume dilation. The final step was manipulation of the shoulder.A paired t test was used to examine the difference in the preprocedure and postprocedure passive range of motion (flexion and abduction). The average shoulder abduction before the procedure was 89.5 degrees ; this improved by an average of 51.7 degrees (P<.0001). The average shoulder flexion improved from 117.3 degrees by an average of 37.7 degrees (P<.0001). There was no significant difference in either abduction or flexion based on age, gender, or chronicity of symptoms. White patients experienced significantly more improvement in abduction than did nonwhite patients.This study suggests that this adhesive capsulitis management protocol is effective and produces a significant improvement in the passive range of motion immediately after the procedure.

  View details for DOI 10.1016/j.pmrj.2009.10.005

  View details for PubMedID 20006315

• Adhesive Capsulitis: A New Management Protocol to Improve Passive Range of Motion PM&R Mitra, R., Harris, A., Umphrey, C., Smuck, M., Fredericson, M. 2009; 1 (12): 1064-1068

  Abstract

  To examine the short-term efficacy of a nonoperative shoulder protocol for the treatment of adhesive capsulitis.A retrospective chart review was used to collect data for a 3-year period.Academic tertiary medical center.28 consecutive patients diagnosed as having adhesive capsulitis were identified and managed with a new protocol.The protocol consisted of the administration of a suprascapular nerve block, the subsequent injection of an intra-articular steroid, and then the injection of an anesthetic agent with brisement normal saline volume dilation. The final step was manipulation of the shoulder.A paired t test was used to examine the difference in the preprocedure and postprocedure passive range of motion (flexion and abduction). The average shoulder abduction before the procedure was 89.5 degrees ; this improved by an average of 51.7 degrees (P<.0001). The average shoulder flexion improved from 117.3 degrees by an average of 37.7 degrees (P<.0001). There was no significant difference in either abduction or flexion based on age, gender, or chronicity of symptoms. White patients experienced significantly more improvement in abduction than did nonwhite patients.This study suggests that this adhesive capsulitis management protocol is effective and produces a significant improvement in the passive range of motion immediately after the procedure.

  View details for DOI 10.1016/j.pmrj.2009.10.005

  View details for Web of Science ID 000208412200003

• Incidence of simultaneous epidural and vascular injection during cervical transforaminal epidural injections. Spine Smuck, M., Tang, C., Fuller, B. J. 2009; 34 (21): E751-5

  Abstract

  Prospective, observational in vivo study.The aim of this study was to determine the incidence of simultaneous epidural and vascular contrast injection during cervical transforaminal epidural injections.In the lumbar spine, vascular contrast patterns are more than twice as likely to appear simultaneous to the anticipated epidural pattern, than they are to occur alone. This is important because practitioners are more likely to miss a vascular pattern when it appears simultaneous to the expected epidural flow. The incidence of intravascular penetration in cervical transforaminal epidural injections is known to exceed than that of lumbar injections, however, no study has determined the incidence of simultaneous epidural and vascular injection in the cervical spine.Contrast patterns were observed with live fluoroscopy during 121 injections performed on 82 patients and categorized as one of the following: epidural only, vascular only, or simultaneous epidural and vascular.The incidence of simultaneous epidural and vascular injection during cervical transforaminal epidural injections was 18.9%. The incidence of vascular only injection was 13.9%, for a total vascular injection incidence of 32.8%. There was no correlation between the observed contrast pattern with patients' age, sex, side of injection, needle gauge, or diagnosis. There was a significant correlation between the level of injection and the risk of vascular injection. The higher the injection level, the higher the probability of a vascular injection. Fluoroscopy time was significantly increased when a vascular injection was identified.Simultaneous epidural and vascular injection accounts for over half of all vascular injections during cervical transforaminal epidural injections. With the risk of severe complications and high incidence of vascular injections in the cervical spine, live fluoroscopy is recommended during contrast injection with specific attention to simultaneous epidural and vascular flow.

  View details for DOI 10.1097/BRS.0b013e3181b043d1

  View details for PubMedID 19934794

• 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

• Blind Man's Bluff SPINE JOURNAL Smuck, M. 2009; 9 (6): 518-519

  View details for DOI 10.1016/j.spinee.2009.04.012

  View details for Web of Science ID 000266893600013

  View details for PubMedID 19465339

• 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

• Considering Industry-Sponsored Research AMERICAN JOURNAL OF PHYSICAL MEDICINE & REHABILITATION Segal, N. A., Smuck, M., Sowa, G., Basford, J. 2009; 88 (4): 342-348

  View details for DOI 10.1097/PHM.0b013e31819111ec

  View details for Web of Science ID 000264451800014

  View details for PubMedID 19077668

• The use of epidural corticosteroids for cervical radiculopathy: an interlaminar versus transforaminal approach. PM & R : the journal of injury, function, and rehabilitation Smuck, M., Rosenberg, J. M., Akuthota, V. 2009; 1 (2): 178-184

  View details for DOI 10.1016/j.pmrj.2008.12.001

  View details for PubMedID 19627891

• Cervical Injections: Is the Risk Worth the Benefit? SpineLine Fish D, Behr J, Smuck M 2009; 10 (1): 18-22
• Interpretation of Contrast Dispersal Patterns by Experienced and Inexperienced Interventionalists PM&R Smuck, M., Abbott, Z., Zemper, E. 2009; 1 (1): 55-59

  View details for DOI 10.1016/j.pmrj.2008.06.001

  View details for Web of Science ID 000208411000009

• Tissue injury and healing Sports Medicine and Rehabilitation: A Sport-Specific Approach Christensen-Holz S, Smuck M 2009; 2nd ed.: 17-22
• Mountain Biking Injuries Sports Medicine and Rehabilitation: A Sport-Specific Approach Smuck M 2009; 2nd ed.: 119-128
• Interpretation of contrast dispersal patterns by experienced and inexperienced interventionalists. PM & R : the journal of injury, function, and rehabilitation Smuck, M., Abbott, Z., Zemper, E. 2009; 1 (1): 55-59

  Abstract

  Determine how accurately inexperienced interventionalists interpret epidural contrast dispersal patterns compared with experienced interventionalists.Prospective comparative study.University spine center.Two experienced interventionalists and 3 pain fellows in training.Each participant independently interpreted 100 images showing contrast dispersal patterns from transforaminal epidural injections. All images were obtained by another physician after 0.5 mL of contrast material was injected. The true contrast dispersal pattern was determined under live fluoroscopy during the injection and classified as follows: epidural only, vascular only, or simultaneous epidural and vascular. Participants were told to assume that 0.5 mL of contrast had been injected before each image and were asked to describe the contrast patterns as epidural, vascular, both, or neither.Variance in agreement with the true contrast patterns between experienced and inexperienced participants.Overall, the inexperienced participants were in exact agreement with the true pattern in 52% of the images versus 70% for experienced participants (P=.03). Experienced participants correctly identified epidural contrast patterns with greater accuracy than inexperienced participants (94% and 76%, respectively; P=.01). Not surprisingly, the accuracy for all participants was low in the identification of vascular patterns on these static images, with 73% accuracy for the experienced and 68% for the inexperienced (P=.18).Even with 6 months of intensive experience, trainees are significantly less accurate than experienced physicians in the interpretation of contrast dispersal patterns from transforaminal epidural injections. The competency of interventional trainees and the amount of experience necessary to safely perform epidural injections deserve further examination.

  View details for DOI 10.1016/j.pmrj.2008.06.001

  View details for PubMedID 19627873

• Intravascular Injection of Contrast During Lumbar Discography: A Previously Unreported Complication PAIN MEDICINE Smuck, M., Yoon, T., Colwell, M. 2008; 9 (8): 1030-1034

  Abstract

  Report a case of intravascular contrast injection during lumbar discography.An academic University spine center.Forty-year-old woman with L5-S1 degenerative disk disease and persistent low back pain.The patient failed to respond to multiple conservative treatments. In consideration of surgical treatment, discography was requested.A 22G needle was inserted to the central nucleus by a left posterolateral approach. Discography was performed at L4-5 and L5-S1. Testing was performed with pressure manometry, beginning with the L4-5 disk. The pressure increased with contrast injection in the manner of a normal disk. At 45 psi there was a sudden drop to 20 psi. Lateral views obtained during contrast injection demonstrated flow from a central nucleogram cephalad into the anterior epidural space. Images obtained with live fluoroscopy demonstrated a vascular flow pattern, confirmed with lateral and anterior-posterior views. The needle tip was repositioned anterior and superior. Repeat injection resulted in an identical vascular pattern. From the time the pressure dropped, contrast flowed in the vascular pattern without propagation of the nucleogram or increase in intradiscal pressure. The patient was asymptomatic throughout the injection at L4-5. Injection at L5-S1 demonstrated a severely degenerative nucleogram and reproduced the patient's usual low back pain.Vascular uptake of contrast can occur during lumbar discography, even when the needle tip is ideally located.

  View details for DOI 10.1111/j.1526-4637.2008.00532.x

  View details for Web of Science ID 000261106100011

  View details for PubMedID 19067829

• Nociception before and after exercise in rats bred for high and low aerobic capacity NEUROSCIENCE LETTERS Geisser, M. E., Wang, W., Smuck, M., Koch, L. G., Britton, S. L., Lydic, R. 2008; 443 (1): 37-40

  Abstract

  Exercise and stress are known to influence pain perception. However, little is known about how level of fitness influences pain perception and the experience of pain. In the present study, pain perception before and after exercise to exhaustion was examined in 6 rats systematically bred to have a high aerobic capacity (HCR animals) and 6 rats systematically bred to have a low aerobic capacity (LCR animals). HCR animals had significantly higher pain thresholds compared to LCR animals before and after exercise (7.66 s compared to 6.01 s, t=-3.07, p<0.05; and 6.89 s versus 4.73 s, t=-3.73, p<0.01, respectively). In addition, both groups of animals displayed evidence of hyperalgesia following exercise compared to baseline. However, the pain thresholds of HCR animals returned to baseline levels faster than LCR animals following exercise. The findings support the hypothesis that level of fitness plays a role in the perception of pain. In addition, a higher level of fitness may serve as buffer against the effects of stress and help to reduce or prevent the experience of clinical pain. Further research is needed to examine the mechanisms that underlie this phenomenon.

  View details for DOI 10.1016/j.neulet.2008.07.040

  View details for Web of Science ID 000259312600008

  View details for PubMedID 18657596

• Accuracy of intermittent fluoroscopy to detect intravascular injection during transforaminal epidural injections SPINE Smuck, M., Fuller, B. J., Chiodo, A., Benny, B., Singaracharlu, B., Tong, H., Ho, S. 2008; 33 (7): E205-E210

  Abstract

  Prospective validity study.To determine how accurately intermittent fluoroscopy detects inadvertent intravascular injection during transforaminal epidurals.Serious morbidity caused by transforaminal epidural injections is frequently related to inadvertent vascular injection of corticosteroids. Several methods have been proposed to reduce the risk of vascular injection, but none have demonstrated efficacy. Because of the fleeting appearance of vascular contrast patterns, live fluoroscopy is recommended during contrast injection. Despite this, many practitioners continue to use intermittent fluoroscopy.During 50 epidural injections dynamic contrast flow was observed under live fluoroscopy, and the "dynamic true" image was determined. Two intermittent fluoroscopy images were saved from each injection, the first just before completing the contrast injection ("static C" image), and another 1 second after the contrast injection ceased ("static PC" image). Five physicians with experience performing these injections independently interpreted the 100 randomly ordered static images. Accuracy of intermittent fluoroscopy was determined by comparing the interpretation of the 100 static images with the dynamic true patterns observed under live fluoroscopy.Overall, interpretation of the static images missed 57% of the vascular injections. Timing of the static images influenced accuracy with the static C images missing 50% of vascular injections, and the static PC images missing 68% of vascular injections (P = 0.075). Accuracy was significantly worse when vascular injections occurred simultaneous to the expected epidural injection (P = 0.041), and in lumbar images (P = 0.012).Based on these findings, we recommend use of live fluoroscopy to observe dynamic contrast flow during transforaminal epidural steroid injections.

  View details for Web of Science ID 000254652000028

  View details for PubMedID 18379390

• Literature Review: New From the Journals SpineLine Smuck M, Levin J, Arnold P 2008; 9 (6): 34-37
• Sacroiliac joint pain in athletes: A biomechanical treatment approach SpineLine Christensen-Holz S, Wiggert B, Smuck M 2008; 9 (6): 30-33
• An unusual cause of S1 radicular pain presenting as early phantom pain in a transfemoral amputee: A case report ARCHIVES OF PHYSICAL MEDICINE AND REHABILITATION Smuck, M., Christensen, S., Lee, S. S., Sagher, O. 2008; 89 (1): 146-149

  Abstract

  Recent epidemiologic studies have shown back pain to be a significant cause of pain in lower-limb amputees, but only a handful of cases have reported sciatica in amputees. The symptoms are usually described as a phantom pain or neuropathic pain in the residual limb that is often refractory to conventional treatments. These symptoms typically occur with back pain and are distinct from the patient's usual symptoms. Interestingly, back pain is not a universal finding. We present a patient with presumed phantom limb pain subsequently discovered to be caused by an S1 radiculopathy. This patient's supposed phantom pain persisted despite multiple medication trials. Initial work-up revealed a sciatic neuroma at the stump. Treatments targeting this neuroma were unsuccessful. Further evaluation found that a sacroiliac joint screw placed to stabilize a pelvic fracture had intruded into the S1 neuroforamen. A diagnostic S1 nerve block temporarily relieved the patient's pain, and the screw was removed. Pain persisted and a spinal cord stimulator was placed resulting in improvement of his pain. Because conventional diagnostic tests are limited, including physical exam and electromyography, a fluoroscopically guided selective spinal nerve block proved to be a useful diagnostic tool in this patient.

  View details for DOI 10.1016/j.apmr.2007.08.135

  View details for Web of Science ID 000252228600023

  View details for PubMedID 18164344

• 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

• Author reply to "Letter to the editor" by Manchikanti and Singh (Spine J. 2007(5)) regarding "Incidence of simultaneous epidural and vascular injection during lumbosacral transforaminal epidural injections" SPINE JOURNAL Smuck, M., Fuller, B. J. 2007; 7 (6): 749-749

  View details for DOI 10.1016/j.spinee.2007.09.002

  View details for Web of Science ID 000251654900021

  View details for PubMedID 17981513

• Irreversible spinal nerve injury from dorsal ramus radiofrequency neurotomy: A case report ARCHIVES OF PHYSICAL MEDICINE AND REHABILITATION Abbott, Z., Smuck, M., Haig, A., Sagher, O. 2007; 88 (10): 1350-1352

  Abstract

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

  View details for DOI 10.1016/j.apmr.2007.07.006

  View details for Web of Science ID 000250161500020

  View details for PubMedID 17908581

• 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: 2. The role of corticosteroids J. Back Musculoskeletal Rehabil Levin J, Smuck M 2007; 20 (2,3): 103-13
• Incidence of simultaneous epidural and vascular injection during lumbosacral transforaminal epidural injections SPINE JOURNAL Smuck, M., Fuller, B. J., Yoder, B., Huerta, J. 2007; 7 (1): 79-82

  View details for DOI 10.1016/j.spinee.2006.06.380

  View details for Web of Science ID 000208746100013

• Radiculopathy from herniation of the nucleus pulposus: 2. The role of corticosteroids JOURNAL OF BACK AND MUSCULOSKELETAL REHABILITATION Levin, J. H., Smuck, M. W. 2007; 20 (2-3): 103-113

  View details for Web of Science ID 000252300300008

• Radiculopathy from herniation of the nucleus pulposus: 1. Epidemiology, pathophysiology, and natural history JOURNAL OF BACK AND MUSCULOSKELETAL REHABILITATION Levin, J. H., Smuck, M. W. 2007; 20 (2-3): 97-101

  View details for Web of Science ID 000252300300007

• Incidence of simultaneous epidural and vascular injection during lumbosacral transforaminal epidural injections. spine journal Smuck, M., Fuller, B. J., Yoder, B., Huerta, J. 2007; 7 (1): 79-82

  Abstract

  The incidence of vascular penetration during contrast confirmed fluoroscopically guided transforaminal lumbosacral epidural injections has been reported as 8.9% to 21.3% depending on the level of injection. Recently, intermittent fluoroscopy was shown to miss more than half of the vascular injections observed under live fluoroscopy. The number of misses increased when epidural and vascular contrast flow appeared simultaneously, even if the fluoroscopic image was taken during contrast injection. To date, no studies have documented the incidence of simultaneous epidural and vascular contrast injections. Also, most previous studies of vascular injections did not document use of live fluoroscopy during contrast injection, so the incidence of vascular injections may be higher than reported.To determine the incidence of simultaneous epidural and vascular contrast injection during lumbosacral transforaminal epidural injections.A prospective, observational, in vivo, study.Patients receiving lumbar transforaminal epidural injections at a university-based outpatient spine center.Incidence of epidural, vascular, and simultaneous epidural and vascular contrast patterns.One interventional spine physician and three fellows under his direct supervision recorded contrast patterns observed during 191 fluoroscopically guided lumbosacral transforaminal epidural steroid injections with injection of contrast observed under live fluoroscopy.The incidence of simultaneous epidural and vascular injection during lumbosacral transforaminal epidural injections was 8.9%. The incidence of a vascular injection alone was 4.2%, for a total vascular injection incidence of 13.1%. Subjects with a simultaneous epidural and vascular injection who returned for repeat injection had a statistically significant chance of a repeat simultaneous epidural and vascular injection when the injection was done at the same location. Fluoroscopy time was significantly increased, an average of 8.8 seconds, when a vascular injection was identified. There was no statistically significant correlation between the incidence of simultaneous epidural and vascular injection with subjects' age, sex, level of injection, side of injection, needle gauge, or diagnosis.Simultaneous epidural and vascular injection is twice as likely to occur as vascular injection alone. Use of intermittent fluoroscopy can miss the transient appearance of the vascular component of these injections, giving the false impression of successful contrast placement. In light of these results, live fluoroscopy is recommended during contrast injection for confirmation of lumbosacral transforaminal epidural injections.

  View details for PubMedID 17197337

• 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
• Therapies for subacute back pain: A glossary approach, Section III Surgery and Injection treatments Back Pain: A Guide for the Primary Care Physician. Haig AJ, Smuck 2005: 308-313
• Sacroiliac joint pain syndrome in active patients: A look behind the pain Physician and Sportsmedicine Chen Y, Fredericson M, Smuck M 2002; 30 (11): 30-37
• Tissue injury and healing, outcomes with the sports medicine approach. Practical Guide to Musculoskeletal Disorders: Diagnosis & Rehabilitation. Smuck M, Buschbacker R 2002; 1st ed.: 3-11