Epidural Steroid Injections

Epidural steroid injections (ESIs) have been endorsed by the North American Spine Society and the Agency for Healthcare Research and Quality (formerly, the Agency for Health Care Policy and Research) of the Department of Health and Human Services as an integral part of nonsurgical management of radicular pain from lumbar spine disorders.
Radicular pain is frequently described as a sharp, lancinating, radiating pain, often shooting from the low back down into the lower limb(s) in a radicular distribution. Radicular pain is the result of a nerve root lesion and/or inflammation. Clinical manifestations of nerve root inflammation include some or all of the following: radicular pain, dermatomal hypesthesia, weakness of muscle groups innervated by the involved nerve root(s), diminished deep tendon reflexes, and positive straight or reverse leg–raising tests. In contrast to oral steroids, ESIs offer the advantage of a more localized medication delivery to the area of affected nerve roots, thereby decreasing the likelihood of potential systemic side effects. Studies have indicated that ESIs are most effective in the presence of acute nerve root inflammation.
The first documented epidural medication injection, which was performed using the caudal approach (see Approaches for Epidural Injections), was performed in 1901, when cocaine was injected to treat lumbago and sciatica (presumably pain referred from lumbar nerve roots).^[1] According to reports, epidurals from the 1920s-1940s involved using high volumes of normal saline and local anesthetics. Injection of corticosteroids into the epidural space for the management of lumbar radicular pain was first recorded in 1952.
ESIs can provide diagnostic and therapeutic benefits. Diagnostically, ESIs may help to identify the epidural space as the potential pain generator, through pain relief after local anesthetic injection to the site of presumed anatomic pathology. In addition, if the patient receives several weeks or more of pain relief, then it may be reasonable to assume that an element of inflammation was involved in his or her pathophysiology. Since prolonged pain relief is presumed to result from a reduction in an inflammatory process, it is also reasonable to assume that during the period of this analgesia, the afflicted nerve roots were relatively protected from the deleterious effects of inflammation. Chronic inflammation can result in edema, wallerian degeneration, and fibrotic changes to the neural tissues.
In these authors' opinion, ESIs are best performed in combination with a well-designed spinal rehabilitation program. In most cases, epidural injections should be considered as a treatment option after other treatment attempts (eg, physical therapy, including therapeutic exercise, manual therapy, and medications) have failed to improve the patient’s symptoms. However, ESIs may be indicated earlier in the treatment algorithm in some selected patients. Examples might include patients with medical contraindications to certain oral analgesics and patients whose pain severity substantially limits their ability to appropriately engage in therapeutic exercise.
A variety of approaches can be used to inject corticosteroids into the epidural space (see Approaches for Epidural Injections). For purposes of this article, the authors generally refer to all epidural steroid injections as ESIs, only specifying the specific type of approach if needed for a point of distinction or clarification.

Massage, Traction, and Manipulation

Various forms of massage, traction, and manipulation have been used in medicine throughout the world for several thousand years. Each modality represents an approach to treatment of the musculoskeletal and other systems sought by a steadily increasing number of people. While research on each of these modalities continues, a long-standing variable, the concept of touch, unites them all.
In the 1940s, Rene A. Spitz reported on foundling home infants who, otherwise healthy and well taken care of, failed to thrive and often died in the absence of being held or touched. Kunz and Krieger additionally defined and taught the principles behind the related concepts of healing touch and therapeutic touch in the 1970s. While there is no consensus on the complete physiology of massage, traction, or manipulation, it is generally accepted that there is more to these treatment approaches than just the interaction of mechanical forces and human anatomy. There is a long history of touch as a natural, essential component to healing and health maintenance.
Throughout history, massage has been woven into the cultural context of medicine. Massage may be the earliest and most primitive tool to treat pain.^[1] Massage consists of Eastern and Western variants. In the West, the practice and popularity of massage has varied over time. In recent years, a previous decline in popularity of massage, probably related to technological advancements in medicine, has been reversed into a resurgence of interest. In the US, approximately $2-4 billion is spent annually on visits to massage therapists, which accounted for approximately 26% of the $11.7 billion spent on nontraditional healthcare in the 1990s.
The American people are pursuing massage in increasing numbers for various reasons (eg, relief of pain, relaxation, conditioning). While little doubt exists that massage is beneficial for certain conditions, additional research is needed to establish its profile of efficacy.

Definition of basic massage concepts

Massage is a therapeutic manipulation of the soft tissues of the body with the goal of achieving normalization of those tissues. Massage can have mechanical, neurological, psychological, and reflexive effects. Massage can be used to reduce pain or adhesions, promote sedation, mobilize fluids, increase muscular relaxation, and facilitate vasodilation. Massage easily can be a preliminary treatment to manipulation; however, it clearly targets the health of soft tissues, while manipulation largely targets joint segments.
Massage consists primarily of hand movements, some of which may be traction based. Traction is defined as the act of drawing or pulling or as the application of a pulling force. Traction sometimes involves equipment but also can be applied manually. In addition, traction affects changes in the spinal column itself, with soft tissues only secondarily changed. Effects of massage, like those of traction, tend to be fairly nonspecific.

Western massage

Western massage is the chief type of massage practiced in the United States today. Among the most common types of massage therapy are acupressure (Shiatsu), Rolfing, Swedish massage, reflexology, and release.^[1] Western massage organizes variations of soft-tissue manual therapy into several categories. Pare of France introduced the basic terminology for Western massage to the United States. The essence of Western massage is use of the hands to apply mechanical forces to the skeletal muscles and skin, although the intent may be to affect either the more superficial tissues or the deeper ones. Types of basic Western massage are characterized by whether (1) the focus of pressure is moved by the hands gliding over the skin (ie, effleurage), (2) soft tissue is compressed between the hands or fingers and thumb (ie, pétrissage), (3) the skin or muscle is impacted with repetitive, compressive blows (ie, tapotement), or (4) shearing stresses arecreated attissueinterfaces below the skin (ie, deep friction massage). Forms of Western massage include the following:

• Effleurage

  • In this approach, the practitioner's hands glide across the skin overlying the skeletal muscle being treated.
  • Oil or powder is incorporated to reduce friction; hand-to-skin contact is maintained throughout the massage strokes.
  • Effleurage can be superficial or deep.
  • Light strokes energize cutaneous receptors and act by neuroreflexive or vascular reflexive mechanisms, whereas deep stroke techniques mechanically mobilize fluids in the deeper soft-tissue structures.
  • Deep stroking massage is performed in the direction of venous or lymphatic flow, whereas light stroking can be in any direction desired.
  • Effleurage may be used to gain initial relaxation and patient confidence, occasionally to diagnose muscle spasm and tightness, and to provide contact of the practitioner's hands from one area of the body to another.
  • The main mechanical effect of effleurage is to apply sequential pressure over contiguous soft tissues so that fluid is displaced ahead of the hands as tissue compression is accomplished.
• Pétrissage

  • Pétrissage involves compression of underlying skin and muscle between the fingers and thumb of 1 hand or between the 2 hands.
  • Tissue is squeezed gently as the hands move in a circular motion perpendicular to the direction of compression.
  • The main mechanical effects are compression and subsequent release of soft tissues, reactive blood flow, and neuroreflexive response to flow.
  • Lymphatic pump is a type of pétrissage done to the chest and rib cage of persons with respiratory compromise in order to draw lymph into the thoracic duct and venous circulation as a result of an alternating increase and decrease of pressure on the chest cavity.
• Tapotement

  • This percussion-oriented massage involves striking soft tissue with repetitive blows, using both hands in a rhythmic, gentle, and rapid fashion.
  • Numerous variations can be defined by the part of the hands making an impact with the body.
  • The therapeutic effect of tapotement may result from compression of trapped air that occurs on impact.
  • The overall effect of tapotement may be stimulatory; therefore, healthy persons with increased tolerance for this approach are more likely to find this type of massage useful.
• Deep friction

  • Pressure is applied with the ball of the practitioner's thumb or fingers to the patient's skin and muscle.
  • The main effect of deep friction massage is to apply shear forces to underlying tissues, particularly at the interface between 2 tissue types (eg, dermis-fascia, fascia-muscle, muscle-bone).
  • Deep pressure keeps superficial tissues from shearing so that shear and force are directed at the deeper tissue surface interface.
  • Deep friction massage frequently is used to prevent or slow adhesions of scar tissue

Eastern massage

Over the centuries, Eastern massage systems have been an integral part of the cultures where they are practiced. Systems for evaluation, diagnosis, and treatment generally are not grounded in conventional Western neurophysiology. Eastern massage includes, among other approaches, Shiatsu, a Japanese system based on traditional Chinese meridian theory with principles of Western science. The theory of Shiatsu is based upon the system of the 12 traditional Chinese meridians (ie, major channels) of the body in which the energy, life force, or Chi, circulates. Acupressure pressure points, situated along the course of channels, allow access to these channels. Acupressure applies massage forces, largely through digital pressure, to the same points treated with acupuncture needles. Imbalances of energy along the meridians are believed to cause disease and can be rectified by localized finger pressure.

Reflexology and auriculotherapy

• These systems of massage share the meridian concept with Shiatsu.
• In these approaches, the meridians are believed to have whole body representations on the extremities (similar to the homunculus of the brain).
• The feet (in reflexology) and the ear (in auriculotherapy) have been mapped in detail.

Decongestive Lymphatic Therapy

Decongestive lymphatic therapy is the complex massage approach that includes manual lymphatic drainage (MLD) in addition to compressive bandages, exercises, and skin care. Manual lymphatic drainage consists of gentle massage in the treatment of lymphedema. Proximal areas are treated first to prevent a damming effect; the treatment is thought to stretch the lymphatic collectors and to stimulate the drainage system. The massage is followed by the application of compressive bandages and is incorporated into a complete self-care program.

Massage technique

The practitioner controls several variables of massage, including milieu. Actual application of treatment includes rhythm, rate, pressure, direction, and duration.
Most massage approaches involve a friction-reducing medium, so that the hands of the practitioner move along the patient's skin with minimal friction. Powders or oils often are used. Massage strokes also should be regular and cyclic. The rate of application for massage varies with the type of technique. In some approaches (eg, tapotement, percussion), the rate is several times per second, while in others it is much slower.
The amount of pressure depends upon technique and desired results. Light pressure may produce relaxation and relative sedation and may decrease spasm; breakdown of adhesions and intervention at a deeper tissue level may require heavier pressure. Treatment of edema and stretching of connective tissue generally requires intermediate amounts of pressure. Direction of massage often is centripetal to provide better mobilization of fluids toward the central circulation. The sequence of tissues treated often is performed in a centripetal fashion.
When muscles are treated, motions generally are kept parallel to muscle fibers. If the treatment goal is to reduce adhesions, shearing forces are circular or at least include cross-fiber components. The area to be treated with massage depends upon the condition being treated and may vary from a well-circumscribed area to treatment of contiguous areas.
Duration of treatment depends upon the area being treated, desired therapeutic goals, and patient tolerance. Wide variation exists regarding treatment duration, which often is guided by changes occurring to tissue during massage application. If massage is performed before other treatments, duration may be determined by the result needed in order to optimize the next treatment step. Duration of a massage therapy program can range from 1 week to months and depends upon verifiable therapeutic goals. Patients must be reexamined from time to time, depending upon diagnosis and therapeutic goals, to insure satisfactory progress.

Nonoperative Treatment of Osteoporotic Compression Fractures Overview of Osteoporotic Compression Fractures

Osteoporosis and osteoporotic vertebral compression fractures are commonly encountered clinical problems. The definition of osteoporosis is diminished bone density measuring 2.5 standard deviations below the average bone density of healthy, 25-year-old, same-sex members of the population. In the United States, approximately 35% of women older than 65 years have osteoporosis.
Vertebral compression fracture (seen in the image below) is the most common complication of osteoporosis. More than 700,000 new vertebral compression fractures occur every year in the United States alone, accounting for more than 100,000 hospital admissions and resulting in close to $1.5 billion in annual costs.
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Anteroposterior and lateral radiographs of an L1 osteoporotic wedge compression fracture. Most of patients experiencing an osteoporotic vertebral compression fracture remain asymptomatic or minimally symptomatic; however, a large number of these patients do experience significant pain, resulting in decreased quality of life and disability. Conventional medical treatment for these patients includes pain medication, activity limitation, physical therapy, and (possibly) bracing.^{[1, 2]}
Patients with osteoporotic vertebral compression fractures are usually treated nonoperatively.

Types of vertebral compression fractures

Vertebral compression fractures characteristically demonstrate a wedge-shaped pattern (seen in the images below) with gross collapse of the anterior portion of the vertebral body and relative preservation of the posterior body height.
Anterior wedge compression fracture with an intact posterior vertebral cortex. Osteoporotic spine. Note the considerable reduction in overall bone density and the lateral wedge fracture of L2. A second common form of fracture is a central crush fracture, which frequently occurs in the lower lumbar spine. Increased interpedicular space, involvement of the posterior cortex, or laminar fracture suggest a burst fracture (seen in the image below), which may be unstable.
A vertebral burst fracture.

Etiology of osteoporotic compression fractures

Cortical and trabecular bone loss, as well as disruption of the microarchitecture of bone, are all typical of osteoporosis. Spinal flexion and axial compression have been shown to place maximal stress on the superior endplate of the vertebral body. The asymmetry of the vertebral body produces maximal stress at the anterior aspect of the cortical shell.
A combination of these factors, that is, decreased, asymmetrical, and irregular bone density, is a hallmark of osteoporotic bone loss. Coupled with even minimal flexion and/or axial loading, these factors predispose the osteoporotic vertebrae to wedge-shaped compression fractures, acquired kyphosis, and general height loss.
Once 1 vertebral compression fracture has occurred, a biomechanical environment is created that favors additional fractures. This occurs as a result of the vertebral compression fracture causing an additional kyphosis, shifting the patient's center of gravity anteriorly and producing a longer moment arm. This longer moment arm increases kyphotic angulation and places additional stress on the vertebrae, particularly the vertebrae adjacent to the primary fracture.
Progressive kyphosis, additional fractures, and neurologic changes are potential complications of osteoporotic compression fractures. These complications can be minimized with appropriate, expeditious care.
All vertebral compression fractures require a systematic examination to rule out an underlying systemic illness, such as malignancy, infection, or renal or liver disease.

Therapeutic Exercise

DeLateur defined therapeutic exercise as bodily movement prescribed to correct an impairment, improve musculoskeletal function, or maintain a state of well-being.^[1] It may vary from highly selected activities restricted to specific muscles or parts of the body, to general and vigorous activities that can return a convalescing patient to the peak of physical condition. Therapeutic exercise seeks to accomplish the following goals:

• Enable ambulation
• Release contracted muscles, tendons, and fascia
• Mobilize joints
• Improve circulation
• Improve respiratory capacity
• Improve coordination
• Reduce rigidity
• Improve balance
• Promote relaxation
• Improve muscle strength and, if possible, achieve and maintain maximal voluntary contractile force (MVC)
• Improve exercise performance and functional capacity (endurance)

The last 2 goals mirror an individual's overall physical fitness, a state characterized by good muscle strength combined with good endurance. No matter which types of exercise may be needed initially and are applied to remedy a patient's specific condition, the final goal of rehabilitation is to achieve, whenever possible, an optimal level of physical fitness by the end of the treatment regimen.

Types of therapeutic exercise

Therapeutic exercises aimed at achieving and maintaining physical fitness fall into the following major categories:

• Endurance training
• Resistance training
• Flexibility training

Patient education

Transcutaneous Electrical Nerve Stimulation

Transcutaneous electrical nerve stimulation (TENS) currently is one of the most commonly used forms of electroanalgesia. Hundreds of clinical reports exist concerning the use of TENS for various types of conditions, such as  (LBP), myofascial and arthritic pain, sympathetically mediated pain,  pain, visceral pain, and . Because many of these studies were uncontrolled, there has been ongoing debate about the degree to which TENS is more effective than placebo in reducing pain.^{[1, 2, 3, 4]}
The image below depicts a TENS unit.
TENS (Transcutaneous Electrical Nerve Stimulator). Image courtesy of Wikimedia Commons. The currently proposed mechanisms by which TENS produces neuromodulation include the following:

• Presynaptic inhibition in the dorsal horn of the spinal cord
• Endogenous pain control (via endorphins, enkephalins, and dynorphins)^[5]
• Direct inhibition of an abnormally excited nerve
• Restoration of afferent input

The results of laboratory studies suggest that electrical stimulation delivered by a TENS unit reduces pain through nociceptive inhibition at the presynaptic level in the dorsal horn, thus limiting its central transmission. The electrical stimuli on the skin preferentially activate low-threshold, myelinated nerve fibers. The afferent input from these fibers inhibits propagation of nociception carried in the small, unmyelinated C fibers by blocking transmission along these fibers to the target or T cells located in the substantia gelatinosa (laminae 2 and 3) of the dorsal horn.
Studies show marked increases in beta endorphin and met-enkephalin with low-frequency TENS, with demonstrated reversal of the antinociceptive effects by naloxone.^[6] These effects have been postulated to be mediated through micro-opioid receptors. Research indicates, however, that high-frequency TENS analgesia is not reversed by naloxone, implicating a naloxone-resistant, dynorphin-binding receptor. A sample of cerebral spinal fluid in those subjects demonstrated increased levels of dynorphin A.
The mechanism of the analgesia produced by TENS is explained by the gate-control theory proposed by Melzack and Wall in 1965.^[7] The gate usually is closed, inhibiting constant nociceptive transmission via C fibers from the periphery to the T cell. When painful peripheral stimulation occurs, however, the information carried by C fibers reaches the T cells and opens the gate, allowing pain transmission centrally to the thalamus and cortex, where it is interpreted as pain. The gate-control theory postulates a mechanism by which the gate is closed again, preventing further central transmission of the nociceptive information to the cortex. The proposed mechanism for closing the gate is inhibition of the C-fiber nociception by impulses in activated myelinated fibers.

Classification and Complications of Traumatic Brain Injury

Epidemiology

Traumatic brain injury (TBI), also known as acquired brain injury, head injury, or brain injury, causes substantial disability and mortality. It occurs when a sudden trauma damages the brain and disrupts normal brain function. TBI may have profound physical, psychological, cognitive, emotional, and social effects. The diagnosis of mild TBI appears to be vastly underdiagnosed in the setting of systemic trauma, even in trauma centers.^[1]
According to the Center for Disease Control and Prevention's National Center for Injury Prevention and Control, the following annual statistics apply in the United States^[2] :

• At least 1.4 million people sustain a TBI.
• Approximately 50,000 people die from a TBI.
• Approximately 475,000 TBIs occur among infants, children, and adolescents aged 0-14 years.
• About 80,000-90,000 people experience the onset of a long-term disability due to a TBI.

The following groups are at particular risk for TBI^[2] :

• Males are about twice as likely as females to sustain a TBI.
• Infants and children aged 0-4 and adolescents aged 15-19 years are the 2 age groups at highest risk for a TBI.
• Adults aged 75 years or older have the highest rates of TBI-related hospitalization and death.

A TBI is caused by an excessive force, blow, or penetrating injury to the head. The leading causes of TBI are as follows^[2] :

• Falls (28%)
• Motor vehicle crashes (20%)
• Being struck by or against objects (19%)
• Assaults (11%)

Mortality rates after brain injury are highest in people with a severe TBI. In the first year after a TBI, people who survive are more likely to die from seizures, septicemia, pneumonia, digestive conditions, and all external causes of injury than are other people of similar age, sex, and race.^[3] However, the mortality rate after severe TBI has decreased since the late 20th century.^[4]
In one study, researchers estimated that the economic burden of TBI in the United States was approximately $37.8 billion in 1985.^[5] This estimate included $4.5 billion in direct expenditures for hospital care, extended care, and other medical care and services; $20.6 billion in work-related losses and disability; and $12.7 billion in lost income from premature death.

Post Head Injury Autonomic Complications

Autonomic dysfunction syndrome (ADS) is reported in cases of brain injury (TBI), hydrocephalus,subarachnoid hemorrhage, and intracerebral hemorrhage. ADS is rarely reported without an identified cause. In ADS, altered autonomic activity results in  fever, tachycardia, tachypnea, pupillary dilation, and extensor posturing. In an effort to more precisely characterize this syndrome, a second term for it—paroxysmal autonomic instability with dystonia (PAID)—has come into use.
PAID occurs as a result of severe brain injury (Rancho level ≤ IV) from multiple causes, including traumatic brain injury (TBI), hydrocephalus, brain tumors, subarachnoid hemorrhage, and intracerebral hemorrhage. PAID is a syndrome attributed to altered autonomic activity. Clinical manifestations consist of a temperature of 38.5º C, hypertension, a pulse rate of at least 130 beats per minute, a respiratory rate of at least 140 breaths per minute, intermittent agitation, and diaphoresis; these are accompanied by dystonia (rigidity or decerebrate posturing for a duration of at least 1 cycle per d for at least 3 d).
Other issues that can occur because of autonomic dysregulation are electrocardiographic alterations, arrhythmias, increased intracranial pressure (ICP), hypohidrosis, subnormal temperature in flaccid limbs, and neurogenic lung disease. Usually episodic, PAID first appears in the intensive care setting but may persist into the rehabilitation phase for weeks to months after injury in individuals who remain in a low-response state.
See also the following related eMedicine topics: