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Biomedical subjects

C N Aprill

Publications and source records attributed to C N Aprill.

At least 19 recordsLinked to original sources
PubMed2000

Lumbosacral epidural steroid injections.

Epidural steroid injections for the treatment of low back pain and associated leg pain have been used for half a century. Initial use was empirical and not without controversy. An abundant literature has accumulated describing their use and potential benefit. Previous controlled studies are limited by methodology and technique. A growing body of literature suggests that they exert some of their clinical effect by reducing epidural and perineural inflammation. More current studies using fluoroscopy with radiographic contrast and precise epidural steroid placement suggests they may obviate surgery in some patients with true radicular pain.

Back Pain↗
PubMed1998

Vibration pain provocation can improve the specificity of MRI in the diagnosis of symptomatic lumbar disc rupture.

OBJECTIVE: The purpose of this study was to determine if vibration pain provocation could be combined with magnetic resonance imaging (MRI) to increase its specificity in identifying symptomatic disc disruption identified by discography. DESIGN: Prospective single-blind study. SETTING: Data were collected at a spine specialty clinic and at a diagnostic imaging center. PATIENTS: A total of 206 discs in 78 patients (41 males, 37 females; average age, 39.7 years; range, 18-73 years) were evaluated by MRI, spinous process vibration, and discography. INTERVENTIONS: A hand-held prototype vibrator was applied to the spinous process of each intervertebral disc level to be evaluated. The type of pain provoked with vibration as well as with discography was recorded as painless, dissimilar to clinical pain, or similar/exact reproduction of clinical pain. The discograms and MRI scans were scored on a 0-4 scale. A system was defined for combining the vibration results with MRI. OUTCOME MEASURES: The results of the vibration and MRI were compared with the results of computed tomography/discography to determine how well the results of the evaluations agreed. RESULTS: Vibration pain provocation agreed with discographic pain provocation in 70.9% of the discs. The specificity of MRI compared with discographic findings was only 55.7%. However, this figure improved significantly to 81.3% when relying on the vibration pain provocation in discs with mild or moderate disruption. The sensitivity of the combined evaluation was 85.9% and the accuracy 83.0%. CONCLUSIONS: A small hand-held vibrator could produce pain provocation results similar to those obtained by discography. Results of this noninvasive pain provocation method can improve the specificity and accuracy of MRI in identifying symptomatic disc lesions.

Adolescent↗
PubMed1997

Extradural sensory rhizotomy in the management of chronic lumbar radiculopathy: a minimum 2-year follow-up study.

STUDY DESIGN: Fifty-one consecutive patients who underwent extradural sensory rhizotomy for chronic radiculopathy after lumbar surgery were reviewed retrospectively. OBJECTIVES: To determine the effectiveness of sensory rhizotomy in the management of chronic radiculopathy in patients selected by extensive imaging techniques and selective nerve root sheath injections. SUMMARY OF BACKGROUND DATA: Results of more central ablative procedures for chronic benign pain problems have been disappointing, with variable reports of pain relief. METHODS: Fifty-one patients were reviewed. All patients underwent extensive evaluation to exclude reversible structural lesions, and all had the diagnosis of chronic radiculopathy confirmed by results of clinical and electrophysiologic examination. Selective nerve root sheath injections under fluoroscopic guidance confirmed the symptomatic nature of the segments. All blocks were repeated at least once. All patients underwent selective sensory rhizotomy or, in some cases, complete rhizotomy. After rhizotomy, 37 patients were available to be observed at selected time intervals for a minimum of 2 years. Clinical results were determined by the presence or absence of pain relief (visual analog scale), sensory and motor deficits, narcotic analgesic usage, and the patient's estimation of the effectiveness of the procedure. RESULTS: At 6 months after surgery, all 51 patients and the outcomes of their surgery were available for review. Fifty-five percent of patients rated were believed to have good or excellent outcomes, whereas the remainder had poor or failed outcomes. For the minimum 2-year follow-up period (range, 2-4.2 years), 37 patients were available for review. At final follow-up examination only 19% of the patients maintained good or excellent outcomes. CONCLUSIONS: The results of the rhizotomy procedures deteriorated over time. Possible reasons for the failure, other than temporal deterioration, were anatomic factors and lack of specificity of diagnostic techniques, specifically selective nerve root sheath injection. At this point rhizotomy cannot be recommended with any confidence whatsoever in the setting of chronic lumbar radiculopathy after lumbar surgery.

Adult↗
PubMed1995

The prevalence and clinical features of internal disc disruption in patients with chronic low back pain.

STUDY DESIGN: This was a cross-sectional analytic study of patients with chronic low back pain. OBJECTIVE: To investigate whether the criteria for internal disc disruption, as adopted by the International Association for the Study of Pain, could be satisfied in patients with chronic low back pain and to test whether there were any conventional clinical features that could identify this condition. SUMMARY OF BACKGROUND DATA: Internal disc disruption has been postulated as an important cause of low back pain. To diagnose this condition, the International Association for the Study of Pain taxonomy requires that pain be reproduced on provocation discography and that computed tomography discography reveal internal disc disruption, provided that as a control, stimulation of at least one other disc fails to reproduce pain. METHODS: Ninety-two consecutive patients with chronic low back pain and no history of previous lumbar surgery were studied. Each patient underwent a standard physical examination. Computed tomography discography was performed at a minimum of two levels. RESULTS: The diagnostic criteria for internal disc disruption were fully satisfied in 39% of patients, most commonly at L5-S1 and L4-L5. None of the clinical tests used could differentiate between those patients with internal disc disruption and other patients. CONCLUSIONS: A diagnosis of internal disc disruption can be made in a significant proportion of patients with chronic low back pain, but no conventional clinical test can discriminate patients with internal disc disruption from patients with other conditions.

Adult↗
PubMed1995

The sacroiliac joint in chronic low back pain.

STUDY DESIGN: This was a cross-sectional analytic study. OBJECTIVES: In relation to pain from the sacroiliac joint, this study sought to establish 1) its prevalence, 2) the validity of pain provocation, 3) whether any arthrographic abnormalities predict a response to joint block, and 4) whether certain pain patterns discriminate patients with this diagnosis. SUMMARY OF BACKGROUND DATA: The true prevalence of sacroiliac joint pain is unknown and despite a plethora of clinical tests, none of these tests has been validated against an established criterion standard. To our knowledge, arthrography of the sacroiliac joint had never been studied. METHODS: Forty-three consecutive patients with chronic low back pain maximal below L5-S1 were investigated with sacroiliac joint blocks under image intensifier using radiographic contrast followed by 2% lignocaine. Information was obtained on pain provocation, analgesia, and image pattern. RESULTS: Thirteen patients (30%) obtained gratifying relief of their pain. Nine of these also exhibited tears of their ventral capsule. Groin pain was the only pain referral pattern found to be associated with response to sacroiliac joint block. CONCLUSION: The sacroiliac joint is a significant source of pain in patients with chronic low back pain and warrants further study.

Adult↗
PubMed1994

Sacroiliac joint: pain referral maps upon applying a new injection/arthrography technique. Part II: Clinical evaluation.

STUDY DESIGN: A pain referral map generated from Part I of this study was tested in 54 consecutive patients. Pain diagrams, completed by each patient, were compared to the map generated from sacroiliac injections in 10 volunteers (Part I). Two clinicians, blinded to the examination of each individual, selected the diagrams most consistent with the pain map. OBJECTIVES: To determine the applicability of a pain referral map as a screening tool for sacroiliac joint dysfunction. SUMMARY OF BACKGROUND DATA: Two independent examiners, blinded to the patients' examinations, selected 16 individuals whose pain diagrams most represented the map generated in Part I. There was a 100% concordance of patients selected. All 16 patients selected had a provocation-positive SI joint injection. Ten of these individuals also received lumbar discography and lumbar facet injections. Only the SI injection on the symptomatic side was provocation positive. METHODS: Patients selected for evaluation based on pain mapping received sacroiliac joint injection. Provocation-positive injections were used to confirm the diagnosis of sacroiliac joint dysfunction. Ten subjects subsequently underwent lumbar discography and lumbar facet joint injections to further confirm the diagnosis. RESULTS: Few studies involving low back pain have used pain referral maps. In the present study, patients were successfully screened for sacroiliac joint dysfunction using a pain referral map generated from provocation of asymptomatic volunteers. CONCLUSION: Patients can be successfully screened for sacroiliac joint dysfunction based on comparison with a pain referral map. Further study on the false negative rates of sacroiliac pain maps is needed.

Adult↗
PubMed1994

Clinical features of patients with pain stemming from the lumbar zygapophysial joints. Is the lumbar facet syndrome a clinical entity?

STUDY DESIGN: This study is a prospective cross-sectional analytic study. OBJECTIVES: The authors determined the prevalence and clinical features of patients with pain stemming from the lumbar zygapophysial joints. SUMMARY OF BACKGROUND DATA: Previous studies have demonstrated a wide range of prevalence for zygapophysial joint pain and conflicting results with regard to clinical signs. METHODS: One hundred and seventy-six consecutive patients with chronic low back pain were investigated with a series of screening zygapophysial joint blocks using lignocaine and confirmatory blocks using bupivacaine. RESULTS: Forty-seven percent of patients had a definite or greater response to the screening injection at one or more levels but only 15% had a 50% or greater response to a confirmatory block. Response to zygapophysial joint injection was not associated with any single clinical feature or set of clinical features. CONCLUSIONS: The zygapophysial joint is an important source of pain but the existence of a "facet syndrome" must be questioned.

Adult↗
PubMed1994

The treatment of lumbar spinal pain syndromes diagnosed by discography. Lumbar arthrodesis.

STUDY DESIGN: This retrospective review of patients whose discogenic pain syndromes were treated by lumbar arthrodesis was designed to examine the clinical efficacy of this diagnostic modality and analyze possible confounding variables. OBJECTIVES: Clinical outcome was examined with respect to status of the arthrodesis, discographic diagnosis, and demographic variables. SUMMARY OF BACKGROUND DATA: Discography continues to be a controversial diagnostic technique for spinal pain syndromes. The morphologic information provided by discography is well known. However, disagreement exists concerning the clinical utility of the pain provoked by this modality. METHODS: Forty-eight patients were included in this study. In all patients, the chief complaint was low back pain. In all patients, the definitive diagnostic technique was lumbar discography followed by computerized tomographic scanning. All patients underwent lumbar arthrodesis. Data were collected in four categories: 1) demographic characteristics, 2) physical findings, 3) results of diagnostic studies, and 4) characteristics of surgical procedures. Data from these categories were studied with respect to clinical rating and status of the arthrodesis. RESULTS: Overall, 46% were judged to have a satisfactory clinical outcome at final follow-up. Forty-eight percent were judged to have a solid arthrodesis. CONCLUSIONS: Based on the results of this study, it appears that discogenic pain syndromes can be treated by arthrodesis.

Adult↗
PubMed1994

The relative contributions of the disc and zygapophyseal joint in chronic low back pain.

STUDY DESIGN: A prospective cross-sectional analytic approach was taken. OBJECTIVES: This study sought to determine the relative contribution of the disc and the zygapophyseal joint as a pain source in patients with chronic low back pain. SUMMARY OF BACKGROUND DATA: Previous studies have employed either zygapophyseal joint blocks or discography, but in no studies have both procedures been performed. METHODS: Ninety-two consecutive patients with chronic low back pain were studied using both discography and blocks of the zygapophyseal joints. RESULTS: Thirty-six patients (39%) had at least one positive discogram as defined by exact pain reproduction, an abnormal image, and a negative control. Eight patients responded to both a screening zygapophyseal joint block using lignocaine and a confirmatory block using bupivacaine. Only three patients had both a positive discogram and a symptomatic zygapophyseal joint. CONCLUSIONS: In patients with chronic low back pain, the combination of discogenic pain and zygapophyseal joint pain is uncommon.

Adult↗
PubMed1994

The false-positive rate of uncontrolled diagnostic blocks of the lumbar zygapophysial joints.

One hundred and seventy-six consecutive patients with chronic low back pain and no history of previous lumbar surgery were studied to determine the false-positive rate of single diagnostic blocks of the lumbar zygapophysial joints. All patients underwent diagnostic blocks using lignocaine. Those patients who obtained definite or complete relief from these blocks subsequently underwent confirmatory blocks using bupivacaine. Eighty-three patients (47%) had a definite or greater response to the initial, lignocaine injection at one or more levels but only 26 (15%) had a 50% or greater response to a confirmatory injection of 0.5% bupivacaine. Using the response to confirmatory blocks as the criterion standard, the false-positive rate of uncontrolled diagnostic blocks was 38% and the positive predictive value of these blocks was only 31%. Because the positive predictive value of a test is lower when the pre-test probability (prevalence) is low, and because the prevalence of lumbar zygapophysial joint pain is likely to be less than 50%, uncontrolled diagnostic blocks will always be associated with an unacceptably low positive predictive value. These features render uncontrolled diagnostic blocks unreliable for the diagnosis of lumbar zygapophysial joint pain not only in epidemiologic studies but also in any given patient.

Adult↗
PubMed1994

The value of the provocation response in lumbar zygapophyseal joint injections.

OBJECTIVE: To determine the relationship between pain provocation and the analgesic response in lumbar zygapophyseal joint blocks. DESIGN: Consecutive patients undergoing intraarticular zygapophyseal joint blocks for the investigation of low back pain were included in this prospective study. SETTING: The referred sample was from the metropolitan areas of New Orleans and San Francisco. PATIENTS: Ninety patients with low back pain of > 3 months' duration and no history of lumbar surgery. INTERVENTIONS: All patients underwent one or more intraarticular injections of radiographic contrast followed by lignocaine (lidocaine) 2% into zygapophyseal joints between L2-3 and L5-S1. Those with definite responses at one or more levels underwent confirmatory blocks using 0.5% bupivacaine. OUTCOME MEASURES: Provocation of familiar pain and relief of pain after the injection of local anesthetic. Patients were assessed by an independent observer. RESULTS: A total of 203 joints were studied. Adopting liberal criteria, either exact or similar reproduction of pain on the one hand correlated with either definite or complete relief of pain after a single, analgesic block on the other (p < 0.0001). However, when more stringent criteria were adopted, such as response to a confirmatory block using bupivacaine, there was no significant association. CONCLUSIONS: This study calls into question the validity of pain provocation alone as a criterion standard in patients undergoing diagnostic lumbar zygapophyseal joint blocks.

Adult↗
PubMed1994

Pain from the lumbar zygapophysial joints: a test of two models.

One hundred seventy-six consecutive patients with chronic low-back pain and no history of previous lumbar surgery were studied to test the clinical criteria of Fairbank et al. and Helbig and Lee for zygapophysial joint pain. All patients underwent a history, examination, and a series of zygapophysial joint injections or blocks of the medial branches of the dorsal ramus with lignocaine. Those patients responding to the first series of blocks were given confirmatory blocks using bupivacaine. None of the clinical features tested was found to be associated with response to the confirmatory block. The Fairbank et al. and Helbig and Lee criteria were shown to be unreliable in distinguishing pain of zygapophysial joint origin from pain of other origins.

Adult↗
PubMed1988

A reassessment of Holt's data on: "The question of lumbar discography".

This paper is a detailed critique of Holt's study entitled "The Question of Lumbar Discography." His finding of a 37% false positive rate in asymptomatic volunteers has been used to discredit lumbar discography as a valid diagnostic study in the investigation of low back pain patients with nonprolapsing disc disease of the lumbar spine. The authors show why Holt's paper should no longer be used as scientific and authoritative evidence against the use of discography by today's standards.

Back Pain↗
PubMed1979

Percutaneous catheterization of the gallbladder with ultrasonic guidance.

We have described a case in which the gallbladder was catheterized by the Seldinger technic, using ultrasonic guidance. The biliary tree was flushed until clear and free passage of bile into the duodenum occurred. Thick inspissated bile can cause intrinsic echoes in the gallbladder that can be mistaken for gallstones.

Catheterization↗
PubMed1977

Ultrasound diagnosis of the hyperextended head in breech presentation.

Hyperextension of the fetal head in the breech presentation can be diagnosed by ultrasound. Straightening of the fetal spine and the widest diameter of the skull posterior to the long axis of the spine is diagnostic. Face presentation should also be diagnosable by these criteria.

Adult↗