Outcome of Spine Injections on the basis of MRI Findings. Personal use only. Tobias Dietrich Kantonsspital St.Gallen

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1 Outcome of Spine Injections on the basis of MRI Findings Tobias Dietrich Kantonsspital St.Gallen

2 Evidence for Spinal Injections? Pe Skeletal Radiology 2010 rso na lu se moderate- to-strong evidence supporting the use of therapeutic on ly - transforaminal epidural injections for lumbar nerve-root compression - facet injections for pain arising from cervical, thoracic and lumbar spine - further subgroup analysis is needed to predict which specific patients may receive the most benefit from spinal injections

3 Educational Objective fluoroscopically-guided transforaminal steroid injection to present specific MRI findings predicting a good clinical outcome after therapeutic spine injections

4 Outline 1. Outcome Quantification Tools after therapeutic Spine Interventions 1. Specific MRI findings predicting the Outcome of Spine Injections

5 Outline 1. Outcome Quantification Tools after therapeutic Spine Interventions 1. Specific MRI findings predicting the Outcome of Spine Injections

Impression of Change Scale (PGIC) after treatment on ly Oswestry

6 Patients outcome questionnaires Pe rso na Numerical Rating Scale for Pain (NRS) baseline & after treatment lu se Patient s Global Impression of Change Scale (PGIC) after treatment on ly Oswestry Disability Index / Neck Disability Index baseline & after treatment

7 Numerical Rating Scale for Pain (NRS) 0 = no pain 10 = worst pain Question: Please rate the severity of your pain at this time? Numerical Rating Scale for Pain (NRS): Pre- and post-injection pain levels can easily assessed using the 11-point numeric rating scale (NRS- 11), thus the NRS-11 enjoys widespread clinical use Hartrick et at The numeric rating scale for clinical pain measurement: a ratio measure? Pain Pract 2003;3:310-6 Hurst Assessing the clinical significance of change scores recorded on subjective outcome measures. J Manipulative Physiol Ther. 2004; 27:26-35

Patient s Global Impression of Change Scale (PGIC) Validated 7-point multiple choice scale of patient s quality of life and response to treatment Since your injection, how would you describe the

8 Patient s Global Impression of Change Scale (PGIC) Validated 7-point multiple choice scale of patient s quality of life and response to treatment Since your injection, how would you describe the change in ACTIVITY LIMITATIONS, SYMPTOMS, EMOTIONS, and OVERALL QUALITY OF LIFE, related to your painful condition? much worse - worse - slightly worse - no change - slightly better better - much better Gold standard for measuring clinically relevant improvement (= better & much better) Sensitive to change over time Kamper. et al Global rating of change scales: a review of strengths. J Man Manip Ther. 2009; 17: Fischer et al Capturing the patient s view of change as a clinical outcome measure. JAMA 1999; 282:

9 Oswestry & Neck Disability Questionnaires - measuring degree of disability and quality of life of back pain patients - Oswestry Disability Index: low back pain - Neck Disability Index: neck pain - 10 questions Topics (ODI): pain intensity, sexual function, sleep quality, ability to lifting, personal care, walk, sit, stand, travel, social life - Each topic assessed by 6 multiple choice statements scale of 0-5 Index Scoring 0% to 20%: Minimal disability 21%-40%: Moderate Disability 41%-60%: Severe Disability 61%-80%: Crippling back pain 81%-100%: either bed-bound or exaggeration of symptoms Fairbank JC, Pynsent PB. The Oswestry Disability Index. Spine 2000;25: Fairbank JC, Couper J, Davies JB. The Oswestry Low Back Pain Questionnaire. Physiotherapy 1980; 66:

10 Trial for Pain Questionnaires Purpose of Trial: right balance of suitable, responsive, expenditure of time for daily clinical practice Questionaires: Numerical Rating Scale for Pain, Patient Global Impression of Change, Oswestry & Neck disability questionnaires Conclusions 1. Oswestry & Neck disability questionnaires took too much time to complete without disrupting patient flow through radiology department 2. NRS & PGIC most useful outcome measures in terms of time efficiency, validity, and the extent of information provided, and can even be used in a busy department Peterson C et al. The development and implementation of an outcomes database for imaging-guided therapeutic musculoskeletal injections Skeletal Radiol. 2014

50% patients return questionnaires after injections on ly Peterson C et al The development and

11 Questionnaires at Radiology of Balgrist Pe rso na NRS & PGIC as standard questionnaires for patients outcome lu pretreatment & at 15- minutes, 1 day, 1 week and 1 month after injection se approximately 50% patients return questionnaires after injections on ly Peterson C et al The development and implementation of an outcomes database for imaging-guided therapeutic musculoskeletal injections Skeletal Radiol. 2014

12 Immediate Pain Response = Long Term Effect? Am J Neuroradiol 2013;34: El-Yahchouchi et al. Pain Med Acta Neurochir 2016

13 Immediate Pain Response = Long Term Effect? Cervical & Lumbar Transforaminal Epidural Steroid Injections: - no strong correlation between the outcome questionnaires obtained immediately after the injection and the 2-month outcome of the numerical rating scale for pain & disability questionnaires - The pain scores at 2 weeks did correlate with the 2-month outcomes & were a significant predictor for improvement at 2 months Wald et al Immediate Pain Response Does Not Predict Long-Term. AJNR Am J Neuroradiol. 2013;34: El-Yahchouchi et al. Lumbar Transforaminal Epidural Steroid. Pain Med Antoniadis A, Dietrich TJ, Farshad M. Does pain relief by... Acta Neurochir 2016

14 Outline 1. Outcome Quantification Tools after therapeutic Spine Interventions 1. Specific MRI findings predicting the Outcome of Spine Injections

15 MODIC Changes Spinal Injections Pe rso Eur J Radiol 2014 BMC MSK Disord 2015 Modic 1 T1w T2w na lu STIR Modic 2 se T1w on ly T2w Gad2+ Modic changes have been linked with pain & worse treatment outcomes? presence of Modic changes related to improvement after steroid injections?

16 MODIC Changes Facet Joint Injections Modic 1 Facet Joint Injection T1w T2w STIR fluoro-guided CT-guided PGIC improved Lumbar Steroid Facet Injections - 40 mg triamcinolone acetonide n = 226 patients 1-Month Outcome No Modic changes Modic I Modic II P-value 45% 34% 32% 0.23 PGIC worse 17% 14% 16% 0.66 tendency for patients without Modic changes to have better outcomes Bianchi et al BMC Musculoskelet Disord 2015

17 MODIC Changes Nerve Root Blocks Pe Modic 2 rso T2w T1w na Gad2+ lu CT-guided se fluoro-guided Lumbar Nerve Root Blocks 40 mg triamcinolone acetonide n = 346 patients 1-Month Outcome on ly No Modic changes Modic I & II P-value Baseline NRS 6.6 ± ± month mean NRS 3.6 ± ± Patients with Modic changes on MRI reported significantly lower pain reduction compared to patients without Modic changes Peterson et al Eur J Radiol 2014

cervical nerve root block C7 Outcome data collection: 15

18 Long Term Outcomes CT-guided Indirect Cervical Nerve Root Blocks Pe rso Eur Radiol 2015 na lu se on ly indirect cervical nerve root block C7 Outcome data collection: 15 minutes, 1 month, 3 months, 1 year Bensler et al Eur Radiol 2015

19 1-Month Outcome: CT-guided Indirect Cervical Nerve Root Blocks 112 patients 36 patients ==> surgery after nerve root injection CT-guided Indirect Cervical Nerve Root Blocks 1-Month Outcome All Patients Numerical Rating Scale (=NRS) Bensler et al Eur Radiol 2015 Baseline 15 Minutes 1 Month 6.7 ± * ± * ± 3.1 Non Surgical Patients NRS 6.5 ± * ± * ± 3.0 Surgical Patients NRS 7.0 ± * ± ± 2.4 * = p < compared to baseline indirect nerve root block

Outcomes from CT-guided Indirect Cervical Nerve Root Blocks disc protrusion disc protrusion

circumference disc extrusion = displaced disc material extent is greater than the base of the

surgery compared to patients with protrusion of the disc Only 26 % of patients with

20 Outcomes from CT-guided Indirect Cervical Nerve Root Blocks disc protrusion disc protrusion disc extrusion disc extrusion disc protrusion = broad-based herniation of % of axial circumference disc extrusion = displaced disc material extent is greater than the base of the disc Patients with extrusion of the disc were approximately 3 to 4 times more likely to go to surgery compared to patients with protrusion of the disc Only 26 % of patients with protrusion required surgery compared to 100 % of patients with discal extrusion Bensler et al Eur Radiol 2015

21 Long Term Outcomes from CT-guided Indirect Cervical Nerve Root Blocks 112 patients included 36 patients ==> surgery after nerve root injection 3 months & 1 year results: exclusively patients not requiring surgery after their indirect cervical nerve root block CT-guided Indirect Cervical Nerve Root Blocks 1-Month Outcome All Patients Numerical Rating Scale (=NRS) All Patients PGIC - 37 % Improved Baseline 1 Month 3 Months 1 Year 6.7 ± * ± * ± * ± 2.9 * = p < compared to baseline 54 % Improved 68 % Improved Bensler et al Eur Radiol 2015

compression was significantly linked to treatment

22 Long Term Outcomes from CT-guided Indirect Cervical Nerve Root Blocks 1 year post-injection: nerve root compression was significantly linked to treatment outcome (p = 0.011) nerve root compression Bensler et al Eur Radiol 2015

23 Specific MRI Findings Outcome of Lumbar Spinal Injections Pe rso CT-guided na Skeletal Radiol 2016 December lu se on ly fluoroscopic-guided imaging-guided lumbar transforaminal epidural steroid injection 156 patients, prospective 1-month follow-up outcomes data

51% of patients: clinically relevant improvement on PGIC

Scale: disc protrusion + disc sequestration (p = 0.

24 Specific MRI Findings Outcome of Lumbar Spinal Injections protrusion protrusion sequestration sequestration 1 month outcome: 51% of patients: clinically relevant improvement on PGIC significant improvement on Patient s Global Impression of Change Scale: disc protrusion + disc sequestration (p = 0.03) significant pain reduction on Numerical Rating Scale: disc protrusion + disc sequestration (p = )

baseline: 6.7 ± 2.3 1-month: 3.5 ± 2.8 (p<0.

25 Specific MRI Findings Outcome of Lumbar Spinal Injections grade 3 foraminal nerve root compression L4 right foraminal/ extraforaminal nerve root compression L3 right 1 month outcome: Numerical Rating Scale baseline: 6.7 ± month: 3.5 ± 2.8 (p<0.05) significant pain reduction on Numerical Rating Scale: severe foraminal nerve root compression (p = 0.01) foraminal/ extraforaminal location of disc herniation (p = 0.014)

significant better clinical outcome & pain reduction: Patients without Modic changes Patients with cervical & lumbar

26 Summary Pe Simple, valid and reliable assessment tools for patients outcomes after imaging-guided therapeutic spine interventions can easily be applied at any institution rso na lu se Abnormalities on MRI related with - on ly significant better clinical outcome & pain reduction: Patients without Modic changes Patients with cervical & lumbar nerve root compression Patients with lumbar <disc protrusion + disc sequestration> Patients with lumbar (extra)-foraminal disc herniation

27 Thank you for your attention! Questions? Tobias Dietrich Kantonsspital St.Gallen

Pain Intensity (mark only 1) Personal Care (washing, dressing, etc.) Lifting (mark only 1) Walking (mark only 1) Sitting (mark only 1)

Pain Intensity (mark only 1) Personal Care (washing, dressing, etc.) Lifting (mark only 1) Walking (mark only 1) Sitting (mark only 1) Pain Intensity Personal Care (washing, dressing, etc.) Lifting Walking Sitting Standing Sleeping Sex Life OSWESTRY v2 Patient s copy I have no pain at the moment The pain is very mild at the moment The