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Biomedical subjects

Joshua A Hirsch

Publications and source records attributed to Joshua A Hirsch.

At least 19 recordsLinked to original sources
PubMed2006

Intradiscal therapies for discogenic pain.

Since the first injection of chymopapain in 1963, percutaneous intradiscal therapies have been used to treat discogenic back and leg pain. The percutaneous discectomy techniques treat contained disc herniations not by resecting the prolapsed disc material but rather through central decompression of the disc. By removing a small volume of tissue from the disc nucleus, a large reduction in overall disc pressure is achieved with consequent relief of neural compression. DISC Nucleoplasty and Dekompressor are the two leading percutaneous discectomy technologies currently. Although rigorous clinical testing of their efficacy is ongoing, there has now been a 40-year history confirming the concept of percutaneous disc decompression, and initial results are very promising. Discogenic low back pain can also arise from annular tears and other forms of internal disc derangement (IDD). Annuloplasty techniques, such as IntraDiscal Electrothermal Therapy (IDET) and discTRODE, have been developed over the past decade that thermally treat the lesions of IDD. Although the therapeutic mechanisms of thermal annuloplasty have yet to be fully elucidated, research studies demonstrate that the procedure can be effective for appropriately selected patients with degenerative disc disease characterized by discographically proven painful annular fissures. Other novel intradiscal therapies are emerging for percutaneous treatment of discogenic pain and await more widespread clinical evaluation.

Chymopapain↗
PubMed2006

"SKyphoplasty": a single institution's initial experience.

PURPOSE: The treatment of painful compression fractures has been revolutionized by vertebroplasty and kyphoplasty, two recently developed techniques that continue to evolve. This article describes a new device for the performance of kyphoplasty that uses a polymer device rather than a balloon to create a void in the bone. MATERIALS AND METHODS: In nine consecutive patients, kyphoplasty was performed at 12 vertebral levels with osteoporotic compression with use of the new SKy bone expander polymer device. RESULTS: The device was successful in creating a void in the bone at all levels. The procedure was also effective in alleviating pain from compression fractures. There were no technical failures or complications. CONCLUSION: The SKy bone expander polymer device is effective and safe for the performance of kyphoplasty to alleviate pain from vertebral compression fractures.

Aged↗
PubMed2006

Vertebral augmentation complicated by perioperative addisonian crisis.

BACKGROUND: We describe a case of perioperative Addisonian crisis induced by vertebral augmentation. While several complications of vertebral augmentation have been reported previously, related to the technical procedure, to our knowledge, perioperative Addisonian crisis from vertebral augmentation has not been reported in the literature. OBJECTIVE: To report an Addisonian crisis perioperative to vertebral augmentation. DESIGN: Case report. METHOD: Retrospective case review. RESULTS: The patient had a history of adrenal insufficiency treated previously with steroids. He developed an L3 vertebral compression fracture, failed conservative therapy and was eventually referred for vertebral augmentation. Immediately after starting the procedure, the patient developed profound hypotension unresponsive to intravenous fluids and vasopressors, consistent with Addisonian crisis. After intravenous steroids had resolved the Addisonian crisis, he underwent vertebral augmentation without further complication. CONCLUSION: Addisonian crisis may be triggered by vertebral augmentation. Practitioners need to recognize immediately this potentially lethal disorder in patients with known or suspected adrenal insufficiency and treat with intravenous hydrocortisone.

Addison Disease↗
PubMed2005

Kyphoplasty for vertebral compression fracture via a uni-pedicular approach.

BACKGROUND: Percutaneous kyphoplasty using a bone expander polymer device, such as percutaneous vertebroplasty and balloon kyphoplasty, is a therapeutic intervention for painful osteoporotic vertebral body compression fractures. Typically the procedure involves placement of bilateral Sky Bone Expanders in the fractured vertebral body via a transpedicular approach. We describe performance of "SKy"phoplasty using the Disc-O-Tech Sky Bone Expander (Disc-O-Tech Medical Technologies, Herzliya, Israel, and Monroe Township, New Jersey) via a unilateral transpedicular approach. The advantage of a unilateral approach is that it reduces the risks associated with large-bore needle placement. These risks include pedicle fracture, medial transgression of the pedicle or transgression into the spinal canal, nerve injury, cement leakage along the cannula tract, and spinal epidural hematoma. Additionally, using a unilateral approach reduces operative time and costs. CASE ILLUSTRATION: A 68-year-old man with osteoporosis presented with severe upper back pain which occurred following a fall. The pain was reproducible on palpation of the L1 spinous process. A lumbar spine magnetic resonance imaging (MRI) with STIR (short tau inversion recovery) sequence demonstrated an acute L1 vertebral body compression fracture. A L1 "SKy"phoplasty was performed using a single Sky Bone Expander polymer device via a unilateral transpedicular approach. The patient reported immediate relief of pain after the procedure. He denied any residual back pain at his follow-up visit. He was able to resume his normal activities including walking, which had been inhibited by pain prior to the procedure. CONCLUSION: "SKy"phoplasty can be performed using a single Sky Bone Expander via a unilateral pedicular approach. The key is a medial needle trajectory with a final Sky Bone Expander position in the midline of the vertebral body.

Journal Article↗
PubMed2005

New approach to the management of acute disc herniation.

BACKGROUND: Over 500,000 percutaneous disc decompression procedures have been performed in the past 20 years. Various percutaneous techniques include chemonucleolysis, percutaneous lumbar discectomy, and laser discectomy which have reported success rates in the 70% to 75% range. This retrospective evaluation of 49 patients who underwent nucleoplasty procedures for treatment of herniated discs, evaluates the effectiveness of nucleoplasty in the reduction of pain, improvement of functional activity, and reduction of pain medication. OBJECTIVE: To illustrate the effectiveness of nucleoplasty in reducing low back pain in symptomatic patients with contained herniated discs. STUDY DESIGN: A retrospective, non-randomized study. METHODS: Forty-nine patients with either axial or radicular low back pain who had undergone the nucleoplasty procedure were included in this analysis. Patients were categorized in one of three different groups depending on time elapsed since the procedure was performed: less than 6 months, between 6 months and 1 year, and greater than 1 year. Pain reduction, work impairment, leisure impairment, medication use and patient satisfaction were all recorded during this study. Pain was quantified using a numeric pain scale from 0 to 10. Work and leisure impairment were measured on a scale of 1 to 5, with 1 signifying no impairment and 5 signifying extreme impairment. Medication use and patient satisfaction were also measured on a scale of 1 to 5. RESULTS: Significant pain relief, functional improvement, and a decrease in medication use were achieved following nucleoplasty. There were no complications associated with the procedure. CONCLUSION: Nucleoplasty should be used in those patients who fail conservative medical management including medication, physical therapy, behavioral management, psychotherapy, and who are unwilling to undergo a more invasive technique such as spinal surgery.

Journal Article↗
PubMed2005

CT guided direct transoral approach to C2 for percutaneous vertebroplasty.

BACKGROUND: Percutaneous vertebroplasty is a well-established procedure consisting of the percutaneous injection of a biomaterial, usually Polymethyl methacrylate (PMMA), into a vertebral body. In most cases, this procedure affords significant pain relief and strengthens the bone. Vertebroplasty is most typically performed successfully with patients with acute compression fractures. OBJECTIVE: We report a case of percutaneous vertebroplasty via the transoral approach, performed with computed axial tomography (CT) scan guidance. METHODS: The procedure was performed in a 74-year-old male with a C2 vertebral body lytic lesion. RESULTS: This uncomplicated, minimally invasive procedure relieved the patient's pain. The transoral route is the most direct operative approach to the pathology in the upper cervical spine. CONCLUSION: When used with the CT scanner to facilitate accurate placement of the needle, the transoral approach provides a safe and precise operative approach to the upper cervical spine.

Journal Article↗
PubMed2004

Safety of latest-generation self-expanding stents in patients with NASCET-ineligible severe symptomatic extracranial internal carotid artery stenosis.

BACKGROUND: Patients with symptomatic extracranial internal carotid artery stenosis (> or =70%) benefit from carotid endarterectomy when compared with medical management. However, independent risk factors can significantly increase the combined stroke and death risk after carotid endarterectomy. Carotid angioplasty and stenting (CAS) is a therapeutic option in patients who are otherwise at high risk or ineligible for carotid endarterectomy. Previous-generation self-expanding stents were hampered by length foreshortening, which limited their application in multifactorial occlusive extracranial internal carotid artery stenosis. METHODS: This is a single-center, prospective, open-label, safety study of CAS with the latest-generation self-expanding stents in patients with extracranial internal carotid artery symptomatic stenosis (> or =70%). All patients included were adjudicated to be ineligible for carotid endarterectomy by a vascular surgeon and/or a neurologist according to the exclusion criteria. Primary adverse events included death and all strokes (ipsilateral and contralateral). Secondary adverse events included transient ischemic attack, myocardial infarction, stent thrombosis, need for reintervention, and presence of hematomas. All adverse events were recorded at 24 hours, 30 days, and 6 months after CAS. RESULTS: Between June 1, 2001, and January 30, 2003, 23 consecutive patients (14 women and 9 men; mean age, 65 years; age range, 48-85 years) underwent 24 extracranial CAS procedures with the latest-generation self-expanding stents. All patients had one or multiple criteria for ineligibility according to the North American Symptomatic Carotid Endarterectomy Trial. Extracranial CAS was successful in all patients, with average residual stenosis of less than 20%. One patient (4%) experienced a stroke by the 30-day periprocedure examination. The total number of primary adverse events at 6 months after CAS was 2 strokes (9%), 1 of which was contralateral to the stent placement; there were no deaths. Twenty-two patients were asymptomatic at 6 months, with a modified Rankin scale score of 1 or less. Of the 2 patients who had a stroke, 1 had a follow-up modified Rankin scale score of 3. CONCLUSION: Extracranial CAS with the latest-generation self-expanding stents is a valid alternative treatment in high-risk or North American Symptomatic Carotid Endarterectomy Trial-ineligible patients.

Aged↗
PubMed2004

Persistent nonfused segments of the basilar artery: longitudinal versus axial nonfusion.

Embryologic development of the basilar artery occurs along two axis systems: longitudinal fusion and axial fusion. Longitudinal fusion consists of midline fusion of paired ventral arteries and reflects the simplified pattern of arterial anatomy found in the spinal cord. Axial fusion consists of fusion of the distal basilar artery, which arises from the caudal division of the internal carotid artery, to the midbasilar agenesis to the posterior inferior cerebellar artery termination of the vertebral arteries. Persistent longitudinal nonfusion (or complete duplication) of the basilar artery is very rare, and persistent axial nonfusion is even rarer. We report one case of persistent longitudinal nonfusion of the basilar artery in a 3-year-old boy and a case of persistent axial nonfusion of the basilar artery in a 43-year-old man.

Adult↗
PubMed2004

Balloon kyphoplasty for vertebral compression fracture using a unilateral balloon tamp via a uni-pedicular approach: technical note.

OBJECTIVE: Percutaneous balloon kyphoplasty, like percutaneous vertebroplasty is a therapeutic intervention for painful osteoporotic vertebral body compression fracture. The procedure involves placement of bilateral inflatable balloon tamps in the fractured vertebral body via a bilateral transpedicular or bilateral extra-pedicular approach. We describe performance of balloon kyphoplasty using a unilateral, single, balloon tamp via a unilateral transpedicular approach. The advantages of a unilateral approach are reducing the risk, albeit low, of pedicle fracture, medial transgression of the pedicle and/or transgression into the spinal canal, nerve injury, cement extravasation along the cannula tract, and spinal epidural hematoma. Additionally, operative and anesthesia time is reduced, as well as the costs of balloon tamps, cannulas, and needles. CASE ILLUSTRATION: An 83-year-old woman with osteoporosis presented with severe lower thoracic back pain which occurred when she bent over to lift a heavy box. The pain was reproducible on palpation of the T-11 spinous process. A spine MRI with STIR (short tau inversion recovery) sequence demonstrated a subacute T-11 vertebral body compression fracture with associated edema. A T-11 balloon kyphoplasty was performed using a unilateral inflatable balloon tamp via a unilateral transpedicular approach. The patient reported immediate relief of pain and improvement of visual analog score (VAS) for pain from preoperative 10 to postoperative 2. She was able to ambulate postoperatively whereas preoperatively she was inhibited by pain. CONCLUSION: Balloon kyphoplasty can be performed using a unilateral balloon tamp via a unilateral pedicular approach. The key is a medial needle trajectory with a final balloon position in the midline of the vertebral body.

Journal Article↗
PubMed2003

Non-invasive hemostatic closure devices: "patches and pads".

Initial device technologies developed to obtain hemostasis of percutaneous arteriotomy sites have used sutures or hemostatic plugs. Recently, a new class of noninvasive products have been introduced that promote rapid hemostasis in the form of a patch or pad. The purpose of this article is to review recent innovations using simple, but effective, hemostatic aids.

Animals↗
PubMed2003

Occurrence of new vertebral body fracture after percutaneous vertebroplasty in patients with osteoporosis.

PURPOSE: To investigate the prevalence and findings of vertebral body compression fractures adjacent to those previously treated with percutaneous vertebroplasty. MATERIALS AND METHODS: The findings in 177 patients treated with percutaneous vertebroplasty for more than 2 years were reviewed retrospectively. The following parameters were reviewed: primary diagnosis, patient age and sex, date of treatment with vertebroplasty, vertebral level(s) treated, pedicular approach, and amount of polymethylmethacrylate injected per vertebral body. Patients with acute compression fractures secondary to osteoporosis were selected. RESULTS: Of 177 patients treated with percutaneous vertebroplasty, 22 (12.4%) developed a total of 36 new vertebral body fractures following treatment. Of the 36 newly documented fractures, 24 (67%) involved vertebrae adjacent to the previously treated vertebral level(s), whereas 12 (33%) involved the collapse of nonadjacent vertebrae. In addition, 24 (67%) of the 36 new vertebral fractures occurred within 30 days after treatment of the initial fracture(s). CONCLUSION: A substantial number of patients with osteoporosis develop new fractures after undergoing percutaneous vertebroplasty; two-thirds of these new fractures occur in vertebrae adjacent to those previously treated.

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PubMed2003

Chronic low back pain of facet (zygapophysial) joint origin: is there a difference based on involvement of single or multiple spinal regions?

Facet (zygapophysial) joint pain can be diagnosed by anesthetization of the medial branch divisions of the dorsal rami. In accordance with the criteria established by the International Association for the Study of Pain, lumbar facet (zygapophysial) joints have been implicated as the source of chronic pain in 15% to 45% of the patients with chronic low back pain. The reasons for the wide variations have not been systematically evaluated. This study was designed to determine the prevalence of facet (zygapophysial) joint pain in patients suffering with only low back pain and compare this prevalence to the prevalence in patients with painful involvement of multiple regions of the spine. A total of 300 patients in an interventional pain management setting, presenting and undergoing diagnostic interventional procedures consecutively, either with involvement of a single region (low back only) or multiple spinal regions (low back pain and neck pain or thoracic pain) were evaluated. There were 150 patients in each group. All patients were treated with diagnostic medial branch blocks with 1% lidocaine to test the presence of facet joint pain. Lidocaine-positive patients underwent a subsequent confirmatory block with 0.25% bupivacaine. Medial branches were blocked at two levels to block a single joint. Prevalence of lumbar facet joint pain in patients with low back only was 21%, compared to 41% of the patients with low back pain with involvement of other regions of the spine with controlled comparative local anesthetic blocks. A false-positive rate of 17% in patients with low back pain only and 21% in patients with involvement of multiple regions of the spine was demonstrated with single blocks. This study demonstrated a lower incidence of facet joint pain in patients with spinal pain of a single region in the low back compared to the patients with multiple region involvement of the spine (21% vs 41%), in an interventional pain management setting. These results may not be extrapolated to the general population or chronic low back pain population at large.

Journal Article↗
PubMed2003

Accuracy of precision diagnostic blocks in the diagnosis of chronic spinal pain of facet or zygapophysial joint origin.

CONTEXT: Facet or zygapophysial joint blocks are used extensively in the evaluation of chronic spinal pain. However, there is a continuing debate about the value and validity of facet joint blocks in the diagnosis of chronic spinal pain. The value of diagnostic facet joint injections may have been overlooked in the medical literature. OBJECTIVES: To determine the accuracy of facet joint blocks in the diagnosis of chronic spinal pain of facet joint origin and also determine the rationale, principles, false-positive rate, and diagnostic utility of facet joint blocks as well as prevalence of facet joint pain. METHODS: Relevant literature was identified through searches of MEDLINE, EMBASE (Jan 1966- Mar 2003), manual searches of bibliographies of known primary and review articles, and abstracts from scientific meetings. Studies were selected if they were either placebo-controlled or comparative local anesthetic blocks and met 3 of the 5 criteria established by the Agency for Healthcare Research and Quality. Information extracted from each study included the details about the study, type, design, patient eligibility criteria, and statistical analysis. Studies were excluded from analysis if they were simply a review or descriptive or involved only a single-block. RESULTS: The data showed that there was conclusive evidence demonstrating that facet joints have a nerve supply and are capable of causing pain with provocation in normal volunteers that reproduces typical pain attribution clinically to facet joints. The studies demonstrated a prevalence of facet joint pain in chronic spinal pain patients of 15% to 45% in lumbar spine, up to 48% in thoracic spine, and 54% to 67% in the cervical spine. Single diagnostic blocks showed a false-positive rate of 27% to 63%. CONCLUSION: The diagnostic accuracy of controlled local anesthetic facet joint blocks is high in the diagnosis of chronic spinal pain.

Journal Article↗
PubMed2003

Epidural steroids in the management of chronic spinal pain and radiculopathy.

Epidural injections with or without steroids are used extensively in the management of chronic spinal pain. However, evidence is contradictory with continuing debate about the value of epidural steroid injections in chronic spinal syndromes. The objective of this systematic review is to determine the effectiveness of epidural injections in the treatment of chronic spinal pain. Data sources include relevant literature identified through searches of MEDLINE, EMBASE (Jan 1966- Mar 2003), manual searches of bibliographies of known primary and review articles, and abstracts from scientific meetings. Both randomized and non-randomized studies were included in the review based on the criteria established by the Agency for Healthcare Research and Quality (AHRQ). Studies were excluded from the analysis if they were simply review or descriptive and failed to meet minimum criteria. The results showed that there was strong evidence to indicate effectiveness of transforaminal epidural injections in managing lumbar nerve root pain. Further, evidence was moderate for caudal epidural injections in managing lumbar radicular pain. The evidence in management of chronic neck pain, chronic low back pain, cervical radiculopathy, spinal stenosis, and post laminectomy syndrome was limited or inconclusive. In conclusion, the evidence of effectiveness of transforaminal epidural injections in managing lumbar nerve root pain was strong, whereas, effectiveness of caudal epidural injections in managing lumbar radiculopathy was moderate, while there was limited or inconclusive evidence of effectiveness of epidural injections in managing chronic spinal pain without radiculopathy, spinal stenosis, post lumbar laminectomy syndrome, and cervical radiculopathy.

Journal Article↗