Joshua Rittenberg, MD

Spinal corticosteroid injections (CSI) are often used to treat radicular and axial pain arising from the spine. Systemic corticosteroids are well known to cause immunosuppression, and locally injected spinal CSI are known to have some systemic absorption. However, it is unknown whether spinal CSI increases the risk of systemic viral infections, such as influenza.To determine whether spinal CSI causes an increased risk for influenza infection and whether they reduce the protective effect of vaccination STUDY DESIGN/SETTING: A retrospective cohort study was performed at Kaiser Permanente Northern California, a large healthcare system with a diverse population.Adults (n=60,880) who received a spinal CSI during influenza seasons from 2016 to 2019. A comparison was made with 121,760 case-matched individuals who did not receive a spinal CSI.The primary outcome was odds of influenza diagnosis following spinal CSI compared with case-matched controls. Secondary analysis examined odds of influenza diagnosis based on vaccination status, multiple same-day injections, and epidural versus non-epidural route of injection.The electronic health record and associated research databases were analyzed to identify patients who received a spinal CSI during three consecutive flu seasons, 2016 through 2019. Injections were stratified into epidural versus non-epidural CSI and single injections versus multiple same-day injections. Additionally, the rate of influenza in vaccinated versus non-vaccinated individuals was examined. Inpatient flu diagnosis was used as a proxy for severe disease. After case matching was completed, odds ratios for flu diagnosis were calculated using a logistical regression model.The odds of flu diagnosis following spinal CSI were not increased compared with controls (OR 0.93 [0.87-1.01, 95% Wald CL]). For epidural CSI the OR was 0.91 (0.83-1.00, 95% Wald CL), and non-epidural it was 1.00 (0.89-1.13, 95% Wald CL). There were similar findings for multiple same-day injections and when looking at inpatient flu diagnosis. For vaccinated individuals, the OR for flu following spinal CSI was 0.86 (0.80-0.92, 95% Wald CL), which indicates a protective effect in these patients.Spinal CSI did not increase the odds of subsequently receiving a diagnosis of influenza, regardless of vaccination status, location of injection, single versus multiple same-day injection, or co-morbidity. Vaccination had a protective effect against influenza, and this was not adversely affected by receiving spinal CSI during the flu season.

View details for DOI 10.1016/j.spinee.2022.02.006

View details for PubMedID 35181540

BACKGROUND CONTEXT: Spinal region corticosteroid injections (CSI) are intended to act locally to relieve radicular or axial back pain, however some systemic absorption occurs, potentially placing recipients at risk for immunosuppressive effects of corticosteroids. No previous studies examine whether patients undergoing spinal region CSI are at increased risk for viral infections, particularly influenza-a common viral illness with potentially serious consequences, especially for patients with multimorbidity.PURPOSE: To examine odds of influenza in patients who received spinal region CSI compared to matched controls.STUDY DESIGN: Retrospective cohort study PATIENT SAMPLE: Adults (n = 9196) who received a spinal CSI (epidural, facet, sacroiliac, paravertebral block) during influenza seasons occurring from 2000 to 2020 were 1:1 matched to controls without spinal CSI.OUTCOME MEASURES: The primary outcome was odds of influenza diagnosis in spinal CSI patients compared to matched controls. Predetermined subgroup analyses examined odds of influenza diagnosis based on vaccination status and injection location.METHODS: An institutional database was queried to identify patients that received spinal CSI during influenza season (September 1 to April 30) from 2000 to 2020. Patients were matched by age, sex, and influenza vaccination status to controls without spinal CSI within the specified influenza season. Influenza diagnosis was ascertained using International Classification of Disease (ICD) codes and data was analyzed using multiple logistic regression adjusted for comorbidities associated with increased risk for influenza.RESULTS: 9196 adults (mean age 60.8 years, 60.4% female) received a spinal CSI and were matched to a control. There were no increased odds of influenza for spinal CSI patients as compared to matched controls (OR 1.13, [95% CI, 0.86-1.48]). When subgroups were examined, there was also no increased odds of influenza for spinal CSI patients based on immunization status (unvaccinated or vaccinated) or spinal injection location (epidural or non-epidural).CONCLUSIONS: Spinal region CSI was not associated with increased odds of influenza or reduced vaccine efficacy. This is reassuring given the analgesic and functional restoration benefits of these injections. Assessing risk of viral infection associated with spinal CSI is particularly relevant in the era of the COVID-19 pandemic, and further work is needed to address this issue.KEY WORDS: Steroid, spine, pain, injection, immunosuppression, influenza, vaccine.

View details for DOI 10.1016/j.spinee.2022.01.014

View details for PubMedID 35121154

Although the types and incidence of adverse events (AEs) associated with transforaminal epidural steroid injection (TFESI) have been described, no study has used a systematic standardized questionnaire to solicit AEs from patients to capture an accurate range and incidence of complications.The aim was to systematically identify the types and incidence of AEs associated with TFESI. Additionally, this study evaluated demographic and clinical factors that may predict a higher risk of an AE.This was a retrospective cohort study from a multiphysician academic PM&R clinic.Patients, aged 19 to 89, who underwent a fluoroscopically guided TFESI for lumbosacral radicular pain between 2004 and 2007 were included.The relationship of AEs with gender, age, trainee presence, steroid type, preprocedure visual analog scale (VAS) pain score, systolic blood pressure, fluoroscopy time, and corticosteroid injectate volume was analyzed.Adverse event data were collected using a survey both immediately and at 24 to 72 hours after TFESI. Statistical analysis was performed using the chi-square, Fisher exact, or Wilcoxon rank sum two-sided tests. Logistic regression analysis was also performed. C.P. is the owner of Rehabilitation Institute of Chicago Physiatric Log & Analysis System computer software.In 1,295 consecutive patients undergoing 2,025 TFESI procedures, immediate AEs and delayed AEs occurred after 182 (9.2%) and 305 (20.0%) injections, respectively. The most common immediate AEs were: vasovagal reaction (4.2%) and interrupted procedure from intravascular flow (1.7%). Common delayed AEs included: pain exacerbation (5.0%), injection site soreness (3.9%), headache (3.9%), facial flushing/sweating (1.8%), and insomnia (1.6%). Significant associations were identified between AEs and gender, age, preprocedure VAS, steroid type, and fluoroscopy time. Trainee involvement in the procedure did not impact the complication rate.Fluoroscopically guided lumbosacral TFESI is associated with a similar rate of minor AEs both immediately and 24 to 72 hours after procedure that are typical of other axial corticosteroid injections. Permanent AEs were not found in this sample. The most common AEs associated with TFESI include vasovagal episodes, procedure interruption from intravascular flow, pain exacerbation, injection site soreness, headache, and insomnia.

View details for DOI 10.1016/j.spinee.2015.05.034

View details for PubMedID 26065819

View details for DOI 10.1111/pme.12573

View details for PubMedID 25338774

Lumbar transforaminal epidural injections are commonly utilized to treat radicular pain due to intervertebral disc herniation.This study aims to determine if there was a major difference in effectiveness between particulate and nonparticulate corticosteroids for acute radicular pain due to lumbar disc herniation.A multicenter, double blind, prospective, randomized trial on 78 consecutive subjects with acute uni-level disc herniation resulting in unilateral radicular pain. All subjects received a single level transforaminal epidural steroid injection with either dexamethasone or triamcinolone. Repeat injections were allowed as determined by the blinded physician and subjects. Primary outcomes included: number of injections received, surgical rates, and categorical pain scores at 2 weeks, 3 months, and 6 months. Secondary outcomes included mean Oswestry Disability Index.Both triamcinolone and dexamethasone resulted in statically significant improvements in pain and function at 2 weeks, 3 months, and 6 months, without clear differences between groups. The surgical rates were comparable with 14.6% of the dexamethasone group and 18.9% of the triamcinolone group receiving surgery. There was a statistically significant difference in the number of injections received, with 17.1% of the dexamethasone group receiving three injections vs only 2.7% of the triamcinolone group.Transforaminal epidural corticosteroid injections are an effective treatment for acute radicular pain due to disc herniation, and frequently only require 1 or 2 injections for symptomatic relief. Dexamethasone appears to possess reasonably similar effectiveness when compared with triamcinolone. However, the dexamethasone group received slightly more injections than the triamcinolone group to achieve the same outcomes.

View details for DOI 10.1111/pme.12325

View details for Web of Science ID 000334111300007

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

The objective of this study was to determine the effectiveness of a 2-day course teaching the introductory skills and concepts of lumbar spine procedures to physiatry residents.This is a 3-yr prospective study of a 2-day musculoskeletal course teaching the introductory skills and concepts of lumbar spinal procedures to the residents at a large academic physical medicine and rehabilitation program. The residents attending the course took multiple-choice pretests and posttests as well as participated in a procedural skills competency demonstration.Forty-two residents participated. The results were stratified according to the level of training and repetition of the material and revealed gains of medical knowledge at each level of residency training (P < 0.001). The postgraduate year 2 residents seemed to have the greatest overall improvement (P = 0.04). Half of the residents scored lower than 65% on the pretest, and these residents ultimately had the largest posttest gains. Forty (95.2%) residents achieved a grade of pass in the skills-based test. The residents felt that the course was valuable or extremely valuable.The comprehensive 2-day course teaching the skills and concepts of spinal interventions for physiatry residents enhances medical knowledge as an introduction to interventional spine care. Those who benefited the most were the residents who had the greatest deficit of medical knowledge on this topic before the course. This course curriculum does not replace fellowship training or closely monitored mentorship in the performance of spinal procedures.

View details for DOI 10.1097/PHM.0b013e31826eda9e

View details for Web of Science ID 000315185400008

View details for PubMedID 23051759

To describe the type, incidence, and factors that contribute to adverse events associated with fluoroscopically guided intra-articular sacroiliac joint injections (IASIJ).A retrospective cohort study.Tertiary, academic, outpatient physical medicine and rehabilitation interventional spine clinic.English-speaking adults aged 18-90 years who underwent fluoroscopically guided IASIJ injections between March 8, 2004, and April 19, 2007.After IASIJ injections, 3 senior researchers recorded the presence and types of adverse events. The relationship of adverse events with age, gender, fluoroscopy time, vital signs, and trainee presence was analyzed with the Fisher exact or the Wilcoxon rank sum 2-sided tests.The frequency of immediate (during or immediately after the procedure) or delayed (within 24-72 hours after the procedure) adverse events.A total of 162 patients (133 women) underwent 191 procedures. The range of subject age was from 20 to 90 years (15.8 years, standard deviation [SD]). The range (SD) of the preprocedure 11-point Likert Pain Scale was from 1.0 to 10.0 (2.0) and for the postprocedure 11-point Likert Pain Scale was from 0.0 to 9.0 (2.5). Trainees were involved in 57% of the procedures. Reported immediate adverse events were vasovagal reaction (2.1% [n = 4]) and steroid-clogged needle (0.5% [n = 1]). Follow-up data were available for 132 of 191 procedures (69%). There were 32 adverse events reported at a mean follow-up interval of 2 days, of which, the most frequent adverse events were injection-site soreness (12.9% [n = 17]), pain exacerbation (5.3% [n = 7]), and facial flushing and/or sweating (2.3% [n = 3]). Delayed adverse events decreased with older age (P = .0029). The patients who underwent bilateral procedures experienced more delayed adverse events than the patients who underwent unilateral procedures (P = .024).Fluoroscopically guided IASIJ injection is associated with minimal adverse effects. The most common immediate adverse event was vasovagal reaction, and the most common delayed adverse event was injection-site soreness. Younger age is significantly related to reported delayed adverse events.

View details for DOI 10.1016/j.pmrj.2012.02.001

View details for Web of Science ID 000306987800002

View details for PubMedID 22543036

View details for DOI 10.1097/BRS.0b013e3181f2ed2f

View details for Web of Science ID 000287446300009

View details for PubMedID 21270713

The determination of whether a patient should pursue an active or passive treatment program is often made by medical practitioners. Knowledge about all forms of treatment, including complementary and alternative (CAM) treatments, is essential in the treatment of low back pain. Medical practitioner-directed active treatments that have been shown to be effective for the treatment of low back pain include physical therapy-directed exercise programs such as core stabilization and mechanical diagnosis and therapy (MDT). Based on the current literature, it appears that yoga is the most effective nonphysician-directed active treatment approach to nonspecific low back pain when comparing other CAM treatments. Acupuncture is a medical practitioner-directed passive treatment that has been shown to be a good adjunct treatment. More randomized controlled studies are needed to support both CAM treatments and exercise in the treatment of low back pain.

View details for DOI 10.1016/j.pmr.2010.06.006

View details for Web of Science ID 000284790100008

View details for PubMedID 20977960