Bio


Dr. Matthew Smuck is the Chief of PM&R and Associate Professor in the Department of Orthopaedic Surgery at Stanford University. He is also the Medical Director of Rehabilitation Services for Stanford Healthcare where he specializes in the comprehensive conservative management of spine disorders. He is a physician leader currently sitting on the Board of Directors for the North American Spine Society, the Spine Intervention Society, and the Foundation for PM&R. He served as Deputy Editor of The Spine Journal and Co-Editor of the Orthopedics Knowledge Update in Spine (4th ed.). Dr. Smuck is also an award-winning researcher who pioneered the new field of physical performance monitoring. He directs the Wearable Health Lab at Stanford, investigating medical applications of mobile technology to improve musculoskeletal and neurologic disease detection, treatment and prevention. His work has received numerous research society awards and publication awards, including the American Academy of PM&R’s 2014 President’s Citation Award, the PM&R Journal and Foundation for PM&R’s 2015 Best Original Research Award, the 2016 ISSLS Prize, and The Spine Journal’s Outstanding Paper Award in 2013, 2016 & 2017. He regularly lectures on his research at Universities and medical conferences in the US and abroad.

Clinical Focus


  • Physical Medicine and Rehab
  • Spine
  • Physical Medicine & Rehabilitation

Academic Appointments


Administrative Appointments


  • Director, University of Michigan PM&R Interventional Spine Fellowship (2007 - 2008)
  • Interim Director, The University of Michigan Spine Program (2008 - 2008)
  • Director, Stanford PM&R Spine Fellowship (2009 - 2014)
  • Medical Director of Rehabilitation Services, Stanford University Hospital & Clinics (2011 - Present)
  • Chief, Physical Medicine & Rehabilitation, Stanford University (2011 - Present)
  • Director and Founder, Wearable Health Lab (2014 - Present)

Honors & Awards


  • Outstanding Paper Award: Surgical Science, The Spine Journal (2017)
  • Runner-up: Outstanding Paper Award: Medical and Interventional Science, The Spine Journal (2017)
  • The ISSLS Prize for Lumbar Spine Research, ISSLS (2016)
  • Runner-up: Outstanding Paper Award: Medical and Interventional Science, The Spine Journal (2016)
  • Best Original Research Award, Foundation for Physical Medicine and Rehabilitation and the PM&R Journal (2015)
  • President's Citation Award, AAPM&R (2014)
  • Best Pain and Spine Abstracts, American Academy of Physical Medicine & Rehabilitation (2014, 2013)
  • Best Papers, North American Spine Society (NASS) Annual Meeting (2013, 2009)
  • Instructor, International Spine Intervention Society (2013)
  • Outstanding Paper Award: Medical and Interventional Science, The Spine Journal (2013)
  • Best Clinical Research Award, International Spine Intervention Society (2014, 2013, 2012)
  • Medtronic Best Poster Award, International Society for the Study of the Lumbar Spine (2012)
  • Best Basic Science Research Award, International Spine Intervention Society (2011)
  • Best Musculoskeletal Research Award, American Academy of Physical Medicine & Rehabilitation (2011)
  • Jose C. Montero MD Teaching Award, Stanford University, PM&R residency program (2010)
  • Faculty Mentor, 1st Place Theodore M. Cole Resident Research Award, University of Michigan (2009, 2007, 2004)
  • Young Investigator Award, US Bone and Joint Decade (2006)
  • Most Outstanding Biomedical Research Paper, Indiana University School of Medicine (1997)

Boards, Advisory Committees, Professional Organizations


  • Board of Directors, Foundation for PM&R (2016 - Present)
  • Board of Directors, North American Spine Society (NASS) (2015 - Present)
  • Board of Directors, Spine Intervention Society (SIS) (2013 - Present)
  • North American Representative, ICHOM Low Back Pain Steering Group (2014 - Present)
  • Deputy Editor, The Spine Journal (2011 - Present)
  • Assistant Editorial Board, European Spine Journal (2011 - Present)
  • Chair, Research Division, Spine Intervention Society (SIS) (2013 - 2015)
  • Co-Chair, North American Spine Society 2013 annual meeting (2013 - 2014)
  • Chair, NASS Advanced Lumbar Spinal Injections Course (2011 - 2015)
  • Co-Editor, Orthopedics Knowledge Update (OKU) Spine, 4th edition (2011 - 2012)
  • Vice Chair, Spine and Pain Track, AAPM&R Program Planning Committee (2010 - Present)
  • Section Editor, Spine & Sports, SpineLine (2008 - 2013)

Professional Education


  • Residency:Stanford University School of Medicine Registrar (2001) CA
  • Board Certification: Physical Medicine and Rehab, American Board of Physical Medicine and Rehab (2002)
  • Board Certification: Pain Medicine, American Board of Physical Medicine and Rehab (2003)
  • Fellowship:Stanford University Hospital - Interventional Spine (2002) CA
  • Internship:Oakwood Healthcare System (1998) MI
  • Medical Education:Indiana University School of Medicine (1997) IN
  • Fellow, Stanford University, Interventional Spine Medicine (2002)
  • Resident, Stanford University, PM&R (2001)
  • M.D., Indiana University, School of Medicine (1997)
  • B.S., Milligan College, Biology, Humanities, French (1993)

Community and International Work


  • Exercise Committee

    Partnering Organization(s)

    North American Spine Society

    Location

    US

    Ongoing Project

    Yes

    Opportunities for Student Involvement

    No

  • ICHOM Low Back Pain Workgroup

    Partnering Organization(s)

    International Consortium on Health Outcomes Monitoring (ICHOM)

    Location

    International

    Ongoing Project

    Yes

    Opportunities for Student Involvement

    No

Current Research and Scholarly Interests


I direct the Wearable Health Lab at Stanford, investigating medical applications of mobile technology to improve musculoskeletal and neurologic disease detection, treatment and prevention.

2017-18 Courses


Stanford Advisees


All Publications


  • 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

  • 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

  • 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

  • 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

  • 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

    View details for DOI 10.1093/pm/pnv073

    View details for Web of Science ID 000379751800006

  • 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

    View details for DOI 10.1093/pm/pnv015

    View details for Web of Science ID 000373731300007

  • 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

  • [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
  • 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

    View details for PubMedCentralID PMC4564773

  • 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
  • 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
  • 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

    View details for DOI 10.1111/pme.12525

    View details for Web of Science ID 000344244800005

  • 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

  • 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
  • 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

  • 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

  • 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

  • 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

  • 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-
  • Preseason Training for Golfers with Low Back Pain SpineLine Roh EY, G. S. 2012; 13 (1): 17-21
  • 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. 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 Web of Science ID 000282151400003

    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
  • 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
  • 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
  • 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

  • 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: 2. The role of corticosteroids JOURNAL OF BACK AND MUSCULOSKELETAL REHABILITATION Levin, J. H., Smuck, M. W. 2007; 20 (2-3): 103-113
  • 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
  • Radiculopathy from herniation of the nucleus pulposus: 1. Epidemiology, pathophysiology, and natural history J. Back Musculoskeletal Rehabil Levin J, Smuck M 2007; 20 (2,3): 97-101
  • Radiculopathy from herniation of the nucleus pulposus: 2. The role of corticosteroids J. Back Musculoskeletal Rehabil Levin J, Smuck M 2007; 20 (2,3): 103-13
  • 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
  • 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