A Noninvasive Assistant System in Diagnosis of Lumbar Disc Herniation

The purpose of this study is the application of pressure sensors in diagnostics and evaluation of the accuracy diagnostics of lumbar disc herniation at levels L4/L5 and L5/S1 using the aforementioned platform. The motivation behind the idea to apply the pressure measurement platform is the fact that the motor weakness of plantar and dorsal flexia of the feet is one of the absolute indications for the operative treatment of patients with lumbar disc herniation at the indicated levels. In patients, MRI diagnosis of the lumbosacral spine served as the ground truth in the diagnosis of herniation at L4/L5 and L5/S1 levels. The inclusive criteria for the study were the proven muscle weakness based on manual muscle tests performed prior to surgery, after seven days of surgery and after physical therapy. The results obtained with the manual muscular test were compared with the results obtained using our platform. The study included 33 patients who met the inclusion criteria. The results of the measurements indicate that the application of our platform with pressure sensors has the same sensitivity diagnostics as a manual muscle test, when done preoperatively and postoperatively. After physical therapy, pressure sensors show statistically significantly better sensitivity compared to the clinical manual muscle test. The obtained results are encouraging in the sense that the pressure platform can be an additional diagnostic method for lumbar disc herniation detection and can indicate the effectiveness of operative treatment and physical therapy after operation. The main advantage of the system is the cost; the whole system with platform and sensors is not expensive

Can Spinal Manipulation Be Used as an Effective Method to Reduce Pain for Patients with a Lumbar Disc Herniation Compared to Traditional Methods?

OBJECTIVE: The objective of this selective EBM review is to determine whether or not “can spinal manipulation be used as an effective method to reduce pain for patients with a lumbar disc herniation compared to traditional methods?” STUDY DESIGN: A systematic review of one randomized controlled trial, one randomized controlled pilot study, and one double-blind, randomized control trial published in 2010 and after. All studies were published in English. DATA SOURCES: Data sources for this review were articles published in peer-reviewed journals using PubMed Database. OUTCOME(S) MEASURED: The outcome measured was change in pain. This was accomplished by using a Numeric Analog Scale (NAS), Aberdeen Back Pain Scale, and a Visual Analogue Pain Scale (VAS). RESULTS: McMorland et al. proved that spinal manipulation was effective in decreasing pain and should be considered for patients prior to resorting to surgery. This study was statistically significant (P=0.034). Lopez- Diaz et al. proved that spinal manipulation was effective in decreasing pain and was significantly more successful than traditional physiotherapy techniques (P = 0.004). Demirel et al. found that spinal manipulation can be used as an assistive agent with traditional physiotherapy methods but that there was no significant reduction in pain between groups. No statistically significance was noted in this study. (P =0.789). CONCLUSION: While reduction of pain from baseline was noted in all three studies based on decrease in mean change from baseline, statistical significance was not noted in Demirel et al. Furthermore, each studies reccomendation on when to implement spinal manipulation varied. Thus, the results of this review are inconclusive. Further research with a larger sample size is warranted to determine the benefits of spinal manipulatio

Pain Reduction in Chronic Lumbar Patients Using Spinal Cord Stimulation

Background: Spinal cord stimulation (SCS) is commonly used to treat chronic neuropathic pain. A common indication for the SCS is failed back surgery syndrome (FBSS). There are many interventional approaches to treating lumbar pain; however, the SCS may provide the greatest benefit in terms of health care utilization and overall pain relief to the patient. Objective: The goal of this paper is to assess the effectiveness of SCS compared to conventional therapies such as physical therapy, oral medications, radiofrequency ablations (RFA), epidural steroid injections (ESI), and intrathecal pain pumps (IT pain pump) in patients with chronic lumbar pain due to FBSS. Methods: A comprehensive literature review was conducted to determine the effectiveness of the SCS. Interventions to treat FBSS were identified from least invasive to most invasive. PubMed and Google Scholar were primarily used to search for relevant literature. The following terms were used for this review: “spinal cord stimulation,” “chronic low back pain,” “conservative treatments,” “costs and cost analysis,” and “failed back surgery syndrome.” Discussion: Treatment for chronic lumbar pain begins with minimally invasive treatments such as physical therapy and medication management, and then may progress to more invasive treatments such as ESI, RFA, or IT pain pumps. When compared to these therapies, the SCS was associated with favorable outcomes and found to be more cost effective. Conclusion: For the treatment of chronic lumbar pain, the majority of studies suggest SCS as potentially more cost effective and efficient than conventional therapies; however, a multidisciplinary approach may provide the greatest benefit. SCS therapy may yet play a role in mitigating the financial burden associated with chronic lumbar pain

Epidural Interventions in the Management of Chronic Spinal Pain: American Society of Interventional Pain Physicians (ASIPP) Comprehensive Evidence-Based Guidelines.

BACKGROUND: Chronic spinal pain is the most prevalent chronic disease with employment of multiple modes of interventional techniques including epidural interventions. Multiple randomized controlled trials (RCTs), observational studies, systematic reviews, and guidelines have been published. The recent review of the utilization patterns and expenditures show that there has been a decline in utilization of epidural injections with decrease in inflation adjusted costs from 2009 to 2018. The American Society of Interventional Pain Physicians (ASIPP) published guidelines for interventional techniques in 2013, and guidelines for facet joint interventions in 2020. Consequently, these guidelines have been prepared to update previously existing guidelines. OBJECTIVE: To provide evidence-based guidance in performing therapeutic epidural procedures, including caudal, interlaminar in lumbar, cervical, and thoracic spinal regions, transforaminal in lumbar spine, and percutaneous adhesiolysis in the lumbar spine. METHODS: The methodology utilized included the development of objective and key questions with utilization of trustworthy standards. The literature pertaining to all aspects of epidural interventions was viewed with best evidence synthesis of available literature and recommendations were provided. RESULTS: In preparation of the guidelines, extensive literature review was performed. In addition to review of multiple manuscripts in reference to utilization, expenditures, anatomical and pathophysiological considerations, pharmacological and harmful effects of drugs and procedures, for evidence synthesis we have included 47 systematic reviews and 43 RCTs covering all epidural interventions to meet the objectives.The evidence recommendations are as follows: Disc herniation: Based on relevant, high-quality fluoroscopically guided epidural injections, with or without steroids, and results of previous systematic reviews, the evidence is Level I for caudal epidural injections, lumbar interlaminar epidural injections, lumbar transforaminal epidural injections, and cervical interlaminar epidural injections with strong recommendation for long-term effectiveness.The evidence for percutaneous adhesiolysis in managing disc herniation based on one high-quality, placebo-controlled RCT is Level II with moderate to strong recommendation for long-term improvement in patients nonresponsive to conservative management and fluoroscopically guided epidural injections. For thoracic disc herniation, based on one relevant, high-quality RCT of thoracic epidural with fluoroscopic guidance, with or without steroids, the evidence is Level II with moderate to strong recommendation for long-term effectiveness.Spinal stenosis: The evidence based on one high-quality RCT in each category the evidence is Level III to II for fluoroscopically guided caudal epidural injections with moderate to strong recommendation and Level II for fluoroscopically guided lumbar and cervical interlaminar epidural injections with moderate to strong recommendation for long-term effectiveness.The evidence for lumbar transforaminal epidural injections is Level IV to III with moderate recommendation with fluoroscopically guided lumbar transforaminal epidural injections for long-term improvement. The evidence for percutaneous adhesiolysis in lumbar stenosis based on relevant, moderate to high quality RCTs, observational studies, and systematic reviews is Level II with moderate to strong recommendation for long-term improvement after failure of conservative management and fluoroscopically guided epidural injections. Axial discogenic pain: The evidence for axial discogenic pain without facet joint pain or sacroiliac joint pain in the lumbar and cervical spine with fluoroscopically guided caudal, lumbar and cervical interlaminar epidural injections, based on one relevant high quality RCT in each category is Level II with moderate to strong recommendation for long-term improvement, with or without steroids. Post-surgery syndrome: The evidence for lumbar and cervical post-surgery syndrome based on one relevant, high-quality RCT with fluoroscopic guidance for caudal and cervical interlaminar epidural injections, with or without steroids, is Level II with moderate to strong recommendation for long-term improvement. For percutaneous adhesiolysis, based on multiple moderate to high-quality RCTs and systematic reviews, the evidence is Level I with strong recommendation for long-term improvement after failure of conservative management and fluoroscopically guided epidural injections. LIMITATIONS: The limitations of these guidelines include a continued paucity of high-quality studies for some techniques and various conditions including spinal stenosis, post-surgery syndrome, and discogenic pain. CONCLUSIONS: These epidural intervention guidelines including percutaneous adhesiolysis were prepared with a comprehensive review of the literature with methodologic quality assessment and determination of level of evidence with strength of recommendations

Doctor of Philosophy

dissertationElectrodiagnostic testing, consisting of needle electromyography and nerve conduction studies, is the primary method used to objectively measure and document pathological changes or injury to the neuromuscular system, including proximally located spinal nerve roots. Clinicians employ electrodiagnostic testing to evaluate patients with low back pain (LBP). One specific cause of LBP is lumbosacral radicular syndrome (LRS), which is commonly known as sciatica or lumbar radiculopathy. The presence of radiating leg symptoms is common to all patients with LRS but radiculopathy is distinguished by the presence of measurable nerve root injury. Little is known about prognostic factors in these patients; however, recent evidence suggests the presence of radiculopathy found on needle electromyography may predict better functional outcomes. The primary purpose of this dissertation work was to investigate the prognostic value of electrodiagnostic testing in patients with LRS receiving physical therapy. Electrodiagnostic testing was performed on 38 patients with LRS participating in a randomized trial comparing different physical therapy treatment programs. Patients were grouped and analyzed according to the presence or absence of radiculopathy. The primary outcome measure was changes in LBPrelated disability assessed using the Roland and Morris disability questionnaire (RMDQ). Patients with radiculopathy (n=19) had statistically significant and iv clinically meaningful improvements in RMDQ scores at every posttreatment follow-up occasion regardless of physical therapy treatment received. The final multilevel growth model revealed improvements in RMDQ scores in patients with radiculopathy at the 6-week (-8.1, 95% CI, -12.6 to -2.6; P=.006) and 6-month (- 4.1, 95% CI, -7.4 to -0.7; P=.020) follow-up occasions compared to patients without radiculopathy. Physical therapy treatment group was not a significant predictive factor at any follow-up occasion. An interaction between electrodiagnostic status and time revealed faster weekly improvements in RMDQ scores in patients with radiculopathy at the 6-week (-0.72, 95% CI, -1.4 to -0.04; P=.040) through the 16-week (-0.30, 95% CI, -0.57 to -0.04; P=.028) follow-up occasions compared to patients without radiculopathy. The presence of lumbosacral radiculopathy identified with electrodiagnostic testing is a favorable prognostic factor for recovery in LBPrelated disability regardless of physical therapy treatment received

A COMPARISON OF SELECT TRUNK MUSCLE THICKNESS CHANGE BETWEEN SUBJECTS WITH LOW BACK PAIN CLASSIFIED IN THE TREATMENT-BASED CLASSIFICATION SYSTEM AND ASYMPTOMATIC CONTROLS

The purposes of this dissertation were to determine: 1) the relationship betweenmuscle thickness change (MTC) as measured by rehabilitative ultrasound imaging(RUSI) and EMG activity in the lumbar multifidus (LM), 2) if motor control changesproduced by experimentally induced pain are measurable with RUSI, 3) if a differenceexists in MTC between subjects with low back pain (LBP) classified in the treatmentbasedclassification system (TBC) system and controls, 4) if MTC improves followingintervention.Current literature suggests sub-groups of patients with LBP exist and responddifferently to treatment, challenging whether the majority of LBP is nonspecific . TheTBC system categorizes subjects into one of four categories (stabilization, mobilization,direction specific exercise, or traction). Currently, only stabilization subjects receive anintervention emphasizing stability. Because recent research has demonstrated that motorcontrol impairments of lumbar stabilizing muscles are present in most subjects with LBP,it is hypothesized that impairments may be present across the TBC classifications.Study 1: Established the relationship between MTC as measured by RUSI andEMG in the LM. Study 2: Assessed MTC of the LM during control and painfulconditions to determine if induced pain changes in LM and transverse abdominis (TrA)are measurable with RUSI. Study 3: Measured MTC of the LM and TrA in subjects withLBP classified in the TBC system and 20 controls. Subjects completed a stabilizationprogram and were re-tested.The inter-tester reliability of the RUSI measurements was excellent (ICC3,3 =.91,SEM=3.2%). There was a curvilinear relationship (r = .79) between thickness changeand EMG activity. There was a significant difference (p andlt; .01) between control andpainful conditions on 4 of the 5 LM tasks tested and on the TrA task. There was adifference in MTC between subjects and controls on the loaded LM test which varied bylevel and category. All categories were different from control on the TrA. Followingintervention the TrA MTC improved (p andlt; .01). The LM MTC did not (p values from .13-.86).These findings suggest MTC can be clinically measured and that deficits existwithin TBC system. Significant disability and pain reduction were measured

Resident curriculum guidelines for neurosurgery

Journal ArticleThis curriculum was created to detail the body of knowledge that should be attained by an individual completing residency training in neurological surgery. The specific structure of resident education in neurological surgery is defined by the American Board of Neurological Surgery, and each program is examined periodically by the Residency Review Committee. It is not the intent of this curriculum to direct or influence these two entities in any way. The curriculum is meant to serve as a template to be used by individual neurosurgery residency program directors and residents as they see fit. In many respects, this comprehensive and specific curriculum delineates the "ideal," and therefore complete compliance to the curriculum will be difficult or impossible to achieve for most if not all programs. Nevertheless, it represents a goal toward which to strive

The Impact of Spinal Manipulation Therapy (SMT) for Nonspecific Low Back Pain in the Military Population: An Integrative Review with Presentation of the SMT Toolkit to Primary Care Providers

Background: Nonspecific Low Back Pain (NLBP) continues to be a frequent cause for medical care and creates significant direct and indirect costs for the patient and healthcare system. Military members are a unique patient population that is at increased risk for experiencing NLBP. Evidence supports spinal manipulation therapy (SMT) for the treatment of NLBP and clinical practice guidelines (CPG) recommend the use of SMT in the treatment of NLBP. Purpose: The purpose of this integrative review was to determine if SMT is an effective intervention for the military population experiencing NLBP. Presentation and Toolkit: An educational presentation and SMT Toolkit were created, formally presented, and distributed to providers that treat and manage active duty military. The SMT Toolkit is a comprehensive yet consolidated practice guide that includes current evidence, the CPG, local SMT referral options and criteria, provider resources, and patient education information. The DNP student created the SMT algorithm and patient education handout, which are embedded within the toolkit. Outcomes/Discussion: Based on the project’s outcomes, ultimately the integrative review with educational presentation, and SMT Toolkit succeeded in increasing providers’ knowledge and awareness and influenced their practice behaviors. Conclusion: The need to determine the most beneficial, conservative, and cost effective treatment options for NLBP like SMT is more important than ever. Users would benefit from using this DNP project, either through utilization in patient care, replication, or expanding further in a similiar quality improvement project. Future investigators should consider factors that improve utilization and sustainment of practice toolkits