This series of Fact Finders presents a brief summary of the evidence and outlines recommendations regarding the injection of preservative-containing steroid formulations in the epidural space and the practice of swabbing newly opened vial tops before drawing up injectate.The evidence in support of the following facts is presented: (1) No adverse events have been documented from the administration of preservative-containing steroids into the epidural space; however, neurological injuries have been reported following intrathecal injection of these preservatives. (2) Swabbing newly opened vial tops before drawing up an injectate has been a standard procedure in healthcare settings. However, the evidence supporting its efficacy is mixed. While a recent study has found no significant benefit, guidelines from the American Society of Anesthesiologists (ASA), Centers for Disease Control and Prevention (CDC), and World Health Organization (WHO) still recommend this practice. (3) Greater than 60% isopropyl alcohol is not universally effective against all pathogens.

This FactFinder presents a brief summary of the evidence surrounding the safety of epidural steroid injections in patients with severe cervical central canal or neural foraminal stenosis. With proper consideration of anatomy, level, and approach, cervical epidural steroid injection risks may be mitigated in a patient with severe cervical central canal and/or neuroforaminal spinal stenosis.

This FactFinder presents a brief summary of the evidence regarding the safety of gadolinium-based contrast media (GBCM) for spinal interventions.

Biliary complications after orthotopic liver transplantation (OLTx) have a high incidence with inherent risks. Given the rise of obesity and subsequent bariatric surgery, there are new challenges for management, particularly in the setting of bypass anatomy, which is not well described. Trans-gastric remnant endoscopic retrograde cholangiopancreatography (TG-ERCP) is a novel technique that could evolve into a primary tool for the diagnosis and treatment of biliary complications after OLTx. A 35-year-old female with a history of Roux-en-Y gastric bypass (RYGB), decompensated alcoholic cirrhosis, and a MELD of 40 underwent standard OLTx. The postoperative course was complicated by rising liver function tests and common bile duct (CBD) dilatation without graft biliary tree dilation. Due to her bypass anatomy, TG-ERCP was used to diagnose a biliary stricture which was treated with CBD stenting. A gastric remnant gastrostomy tube (G-tube) was placed as easy access for all interval ERCP interventions until stricture resolution. As metabolic dysfunction-associated steatotic liver disease becomes a larger transplant indication, centers will undoubtedly encounter more recipients with RYGB anatomy. When compared to alternative options, TG-ERCP should be the primary tool for the diagnosis and treatment of postoperative biliary complications, given its high success rate with fewer complications and graft vascular injuries. Future cohort-based studies are necessary to validate this approach and the proposed treatment algorithm.

Summary of background:The field of orthobiologics has attempted to address the challenge of discogenic low back pain (LBP). Research in areas such as stem cells, platelet-rich plasma, and specific growth factor injections has seen limited success. Objective:The purpose of this trial was to determine the efficacy of a single intradiscal bone marrow concentrate (BMC) injection on pain and function for chronic discogenic LBP. Methods:Patients with presumed discogenic LBP participated in a prospective, double-blind, randomized, sham controlled trial of a single intradiscal BMC injection compared to a sham procedure. Pain and function were assessed at baseline, 3, 6, and 12 months by Clinical Outcome Measurement Brief Instrument (COMBI) which includes the Numeric Rating Scale (NRS). Function was also assessed by the Oswestry Disability Index (ODI). The primary outcome was based upon clinical success, defined by at least 50 % pain relief from baseline to 3, 6, and 12 months. Results:Sixty-three patients were included in the trial (45 BMC, 18 sham). There were no significant differences in the primary outcome (>50 % relief in NRS) at 3 months (40 % BMC group [95 %CI: 27-50 %] vs 33 % sham group [95 %CI: 15-56 %]), 6 months (40 % BMC [95 %CI: 27-50 %] vs 39 % sham [95 %CI: 20-61 %]), or 12 months (44 % BMC [95 %CI: 31-59 %] vs 56 % sham [95 %CI: 34-75 %]). There were no significant differences in the proportion of patients achieving at least a 30 % improvement on the ODI at 3 months (51 % BMC group [95 %CI: 37-65 %] vs 33 % sham group [95 %CI: 16-56 %]), 6 months (53 % BMC [95 %CI: 39-67 %] vs 44 % sham [95 %CI: 25-65 %]), or 12 months (56 % BMC [95 %CI: 41-69 %] vs 61 % sham [95 %CI: 39-80 %]). Conclusions:Intradiscal BMC was equivalent to a sham procedure for chronic discogenic LBP. Both groups had a high, but statistically equivalent success rate. Unfortunately, the significant limitations of this trial, including lack of quality cell analysis, limit the ability to draw conclusions on the effectiveness of intradiscal BMC.

Summary of background data:The risk of a symptomatic epidural bleed in patients continuing anticoagulation during most types of spinal injection procedures is extremely low. Cervical epidural steroid injections involve a unique risk of a catastrophic complication if an epidural hematoma is to occur secondary to spinal cord compression due to the anatomic confines of the cervical spinal canal. There is minimal research on the risk of cervical transforaminal epidural steroid injections (CTFESI) with anticoagulation. Objective:Evaluate the risk of performing CTFESI with patients continuing prescribed anticoagulation medication. Methods:A retrospective review was performed at two practice settings, a community-based outpatient practice and an academic practice, to identify all CTFESI performed between June 2018 through November 2023. Patient medical records were reviewed for the presence of anticoagulation and NSAID medication the day of the CTFESI. Data analysis used descriptive statistics to summarize the distribution of anticoagulants, NSAIDs, and cervical levels across practices, along with medication frequencies and percentages. Results:A total of 2792 CTFESIs were performed across both settings between June 2018 and November 2023. Of those, 1040 CTFESIs (37.2 %) were performed on patients taking some form of anticoagulant medication. 277 CTFESI were performed on patients taking anticoagulants or aspirin or a combination of anticoagulants and ASA. 763 were performed on patients taking NSAIDs. There were no reported cases of symptomatic epidural hematomas or other bleeding complications in the immediate post-procedural period or up to 1 week following the procedure. Conclusion:It is likely that CTFESI can be safely performed in patients continuing anticoagulation, aspirin (ASA), or NSAIDs. Discontinuing anticoagulants or NSAIDs for CTFESIs may not be necessary. Further studies are warranted to confirm these results.

This series of FactFinders presents a brief summary of the evidence and outlines recommendations to minimize risks associated with cervical epidural injections.Evidence in support of the following facts is presented.Minimizing Risks with Cervical Interlaminar Epidural Steroid Injections – 1) CILESIs should be performed at C6-C7 or below, with C7-T1 as the preferred access point due to the more generous dorsal epidural space at this level compared to the more cephalad interlaminar segments. This reduces the risk of the minor complication of dural puncture and the major complication of spinal cord injury due to inadvertent needle placement. 2) LF gaps are most prevalent in the midline cervical spine. This can result in diminished tactile feedback with loss of resistance (LOR), increasing the risk for inadvertent dural puncture or spinal cord injury. Based on current evidence, needle placement in the paramedian portion of the interlaminar space is safest to avoid LF gaps. 3) An optimal AP trajectory view and the physician's ability to discern engagement in the LF and subsequent LOR are crucial. Confirmation of minimal needle insertion depth relative to the ventral margin of the lamina with either a lateral or contralateral oblique (CLO) safety view is critical to minimize the risk of inadvertently inserting the needle too ventral. 4) There have been closed claims and case reports of patients who have suffered catastrophic neurologic injuries while receiving CILESIs under deep sedation. If sedation is administered, the least amount necessary should be utilized to ensure the patient can provide verbal feedback during the procedure. 5) CILESIs are an elective procedure; therefore, necessity and likelihood of benefit must be foremost considerations. Current guidelines recommend holding ACAP therapy before CILESIs due to the potentially catastrophic complications associated with epidural hematoma (EH) formation. However, there is also a risk of severe systemic complications with ceasing ACAP in specific clinical scenarios. The treating physician is obligated to determine if the procedure is indicated and can ultimately decide to delay the intervention or not perform the procedure if the benefit does not outweigh the risks.Minimizing Risks with Cervical Transforaminal Epidural Steroid Injections – the Role of Preprocedural Review of Advanced Imaging -- Variations in vascular anatomy may warrant a modified approach to CTFESI. Preprocedural review of cross-sectional imaging can provide critical information for safe injection angle planning specific to individual patients and may help to decrease the risk of unintended vascular events with potentially catastrophic outcomes.Safety of Multi-level or Bilateral Fluoroscopically-Guided Cervical Transforaminal Epidural Steroid Injections -- Safe performance of a CTFESI procedure requires the ability to detect inadvertent arterial injection. Contrast medium placed into the epidural space and/or along the exiting spinal nerves during an initial CTFESI may obscure the detection of inadvertent cannulation of a radiculomedullary artery by a subsequent CTFESI. While no available literature directly addresses the potential risk that exists with a multi-level or bilateral CTFESI, caution is still warranted.

BackgroundBoth conservative and surgical treatment options for tendinopathies often have less than ideal outcomes. Platelet-rich plasma (PRP) has become an increasingly popular treatment option with only limited evidence for effectiveness.MethodsA retrospective review was performed of all consecutive patients undergoing PRP for hip tendinopathies during a three-year period in a single outpatient spine and musculoskeletal clinic. Each procedure was performed under ultrasound guidance with a concurrent needle tenotomy. Categorical data analysis was performed to determine percent of patients achieving at least 30%, 50%, and 80% relief of pain as measured by NRS.ResultsA total of 48 patients were included with an average follow period of 14 weeks. Seventy-seven percent of patient achieved at least 30% improvement in pain by NRS (95% CI: 63%-88%), 65% achieved at least 50% improvement in pain (95% CI: 49%-78%), and 27% achieved at least 80 % pain improvement (95% CI: 15%-42%).ConclusionThis retrospective study demonstrates relatively good outcomes for this novel treatment. The results of this single practice audit are similar to previously published retrospective and prospective trials.

Hepatic epithelioid hemangioendothelioma (HEHE) is a rare tumor with currently no established standard of care. This international multicenter retrospective study assesses the use of percutaneous irreversible electroporation (IRE) as an ablative tool to treat HEHE and provides a clinical overview of the current management and role of IRE in HEHE treatment. Between 2017 and 2023, 14 patients with 47 HEHE tumors were treated with percutaneous IRE using CT-scan guidance in 23 procedures. Baseline patient and tumor characteristics were evaluated. Primary outcome measures included safety and effectiveness, analyzed using Common Terminology Criteria for Adverse Events (CTCAE) and treatment response by mRECIST criteria. Secondary outcome measures included technical success, post-treatment tumor sizes and length of hospital stay. Technical success was defined as complete ablation with an adequate ablative margin (intentional tumor free ablation margin > 5 mm). IRE treatment resulted in technical success in all tumors. Following a median follow-up of 15 months, 30 tumors demonstrated a complete response according to mRECIST criteria. The average tumor size pre-treatment was 25.8 mm, accompanied by an average reduction in tumor size by 7.5 mm. In 38 out of 47 tumors, there was no evidence of local recurrence. In nine tumors, residual tumor was present. There were no cases of progressive disease. Median length of hospital stay was one day. Only one grade 3 CTCAE event occurred, a pneumothorax requiring chest tube placement. The current study provides evidence that IRE is a safe and efficacious minimally invasive treatment option for HEHE.

Background:Upper extremity radicular pain is commonly treated with a cervical transforaminal epidural steroid injection (CTFESI). Recently, a new technique, the modified approach CTFESI, has been developed with a theoretical safety advantage to avoid the neurovascular structures. This approach requires an angle measurement of the superior articular process (SAP) on MRI. The inter-rater reliability of this angle measurement among practicing physicians is yet to be investigated. Objective:The purpose of this study was to determine the inter-rater reliability of SAP angle measurements on MRI. Methods:Three raters independently measured the SAP angle on 50 cervical MRIs. A two-way, mixed effects, absolute agreement, single rater statistical model was used to determine the intraclass correlation coefficient (ICC) between all three raters, as well as between each pair of raters. Results:Inter-rater reliability among all raters showed good reliability with an ICC ​= ​0.837709 (95% CI 0.75-0.9, p ​< ​0.001). Similarly, good inter-rater reliability was found between each of the pairs of raters. Conclusion:This study demonstrates good inter-rater reliability of MRI SAP angle measurement among clinicians for use in the modified CTFESI approach.

Background:Prior work demonstrated that a history of episodic low back pain was highly indicative of discogenic pain. Recently, there has been more focus on vertebrogenic pain, however little is known about the clinical features of this condition. Purpose:To determine if a history of severe episodic low back pain correlates with Modic endplate changes on lumbar spine magnetic resonance imaging (MRI), presumed to be a marker of vertebrogenic pain. Study design:/setting: Retrospective, observational, in vivo study of consecutive patients at outpatient Physical Medicine & Rehabilitation clinics at a single academic spine center. Patient sample:Consecutive patients who received a lumbar spine MRI between January 1, 2020, and December 31, 2020. Methods:A retrospective chart review identified patients who received a lumbar spine MRI in 2020. Chart review then determined if patients had a history of episodes of low back pain lasting at least 2 days, or if they had non-episodic low back pain (pain beginning with a gradual onset or after a specific event with continuous symptoms for >3 months). Patients were excluded if they had prior lumbar spine surgery, radicular leg pain without low back pain, indeterminate presentations based on chart review, acute spine fractures, or metastatic spine lesions. For the primary analysis, the MRIs were reviewed and were dichotomized into positive (having for either type 1 or type 2 Modic changes at any level) or negative (no Modic changes at any level). Results:A total of 111 patients were analyzed. Inter-rater reliability for determining whether a patient's low back pain was episodic was strong (kappa ​= ​0.83), as was inter-rater reliability for determining if a patient had any levels with type 1 or type 2 Modic changes (kappa ​= ​0.81). Seventy-one out of 111 patients had type 1 and/or type 2 Modic changes at one or more spinal levels. The sensitivity of the test (episodic vs non-episodic low back pain) in finding patients with Modic changes was 20% and the specificity was 70%. The diagnostic confidence odds were 1.2, with a diagnostic confidence of 55%. Subgroup analyses for type 1 Modic changes, and for type 2 Modic changes, showed similar values. Conclusions:A history of episodic low back pain is not a strong indicator for a vertebrogenic etiology.