The Effect of Social Isolation During the COVID-19 Pandemic on Patients with Chronic Low Back Pain Who Underwent a Spine Intervention

BACKGROUND: The COVID-19 infection poses a serious threat to global health for millions of people. In addition to therapeutic treatment methods, preventive measures are also important in controlling the pandemic. As a result, billions of people are quarantined in their homes to prevent the spread of coronavirus. However, social isolation may result in immobility, which can lead to musculoskeletal problems and an increased level of pain, depending on the weakness of the muscles. OBJECTIVES: To examine the effect of social isolation during the recent COVID-19 pandemic on patients with chronic low back pain. STUDY DESIGN: A total of 145 patients who underwent a spine intervention within the past year were enrolled in this prospective and cross-sectional study. SETTING: The study was performed in the interventional pain unit of a tertiary rehabilitation center in Turkey. METHODS: Patient data were obtained by telephone interview and included information pertaining to demographics, pain history, an assessment of pain, analgesic use, activity levels, and an evaluation of stress and sleep habits. Additionally, the International Physical Activity Questionnaire (IPAQ) was used to evaluate patient activity levels. RESULTS: It was detected that social isolation has increased the intensity of low back pain experienced by patients during the COVID-19 pandemic. We also found that patients who benefited from spinal injections administered in the prepandemic period experience less severe low back pain (P = 0.000) and took fewer analgesics (P = 0.000) during the pandemic. The findings of our study revealed that there was a significant reverse correlation between IPAQ walking scores and the prepandemic Visual Analog Scale (VAS) scores (P = 0.015, r = -0.201) and the pandemic VAS scores (P = 0.000, r = -0.313).By contrast, the level of benefit from injections decreased (P < 0.05) and the duration of spinal intervention was shortened in patients with high IPAQ sitting scores (P < 0.05). LIMITATIONS: The limitations of the study are the small number of patients and the fact that our results are based on patients’ self-reported data. CONCLUSIONS: Social isolation has had an increasing effect on low back pain during the COVID-19 pandemic. The results of our study showed a significant relationship between activity level and pain intensity. We also found that patients who have benefited from spinal injections administered in the prepandemic period experience less severe low back pain during the pandemic. KEY WORDS: COVID-19, spine intervention, physical activity, low back pain, social isolation

Changes in Interventional Pain Physician Decision-Making, Practice Patterns, and Mental Health During the Early Phase of the SARS-CoV-2 Global Pandemic

Background and Objectives The novel coronavirus outbreak (SARS-CoV-2) began in late 2019 and dramatically impacted health care systems. This study aimed to describe the impact of the early phase of the pandemic on physician decision-making, practice patterns, and mental health. Methods An anonymous survey was distributed to physician members of the Spine Intervention Society (SIS) on March 24 and April 7, 2020. Respondents provided information regarding changes in clinical volume, treatment, and mental health (Patient Health Questionnaire [PHQ-4]) before April 10, 2020. Results Of the 1,430 individuals who opened the survey, 260 completed it (18.2%). Overall clinical and procedural volume decreased to 69.6% and 13.0% of prepandemic volume, respectively. Mean in-person clinic visits were reduced to 17.7% of total prepandemic clinic volume. Ongoing clinical visits were predominantly completed via telemedicine (video) or telephone (74.5%), rather than in-person (25.5%). Telemedicine and telephone visits represented 24.6% and 27.3% of prepandemic clinical volume, respectively. Respondents decreased in-person visits of select groups of high-risk patients by 85.8–94.6%. Significantly more providers reported increasing rather than decreasing prescriptions of the following medications: opioids (28.8% vs 6.2% of providers, P &lt; 0.001), muscle relaxants (22.3% vs 5.4%, P &lt; 0.001), neuropathic pain medications (29.6% vs 3.8%, P &lt; 0.001), and acetaminophen (26.2% vs 4.2%, P &lt; 0.001). Respondents’ mean PHQ-4 score was 3.1, with 19% reporting moderate or severe psychological distress. Several demographic factors were significantly associated with practice changes. Conclusions The novel coronavirus pandemic dramatically altered the practice and prescribing patterns of interventional pain physicians.

Prevalence and Discordance of the “Startle Response” with True Discogenic Pain According to Spine Intervention Society Guidelines for Provocation Discography: A Cohort Study

Summary of Background Data The literature on cervical provocation discography (C-PD) is sparse. A “Startle Response” during C-PD is a known phenomenon that might be mistaken as an indicator of discogenic pain at the provoked disc level, but this has not been quantitatively described. Objectives To determine the incidence of the Startle Response and its concordance/discordance with true-positive C-PD in patients referred for surgical planning or evaluation after ruling out other axial pain generators. Methods Retrospective cohort study of consecutive patients who received C-PD at an outpatient spine center. The primary outcome was the rate of discordance of the Startle Response with true-positive C-PD according to the operational criteria of the Spine Intervention Society (SIS) guidelines. Results One hundred five discs were provoked in 36 individuals (19 female, mean age [SD] = 45.7 [10.9] years). C-PD was performed at a median of three levels (range = 1–5) with C4/5 (N = 30), C5/6 (N = 30), and C6/7 (N = 31) the most commonly evaluated. Twenty-six of 36 patients reported responses consistent with true-positive C-PD. A Startle Response was observed in 14 patients (39%, 95% confidence interval [CI] = 23–57%), and 22 of 105 (21%, 95% CI = 14–30%) provoked discs. Of the 14 patients who exhibited a Startle Response, four had negative C-PD results (29%, 95% CI = 8–58%). As assessed per disc, C-PD results were positive in 12 of the 22 (55%, 95% CI = 32–76%) provoked discs that generated a Startle Response. Conclusions The present data demonstrate high discordance, 45% (95% CI = 24–68%), between the Startle Response and true-positive C-PD. Clinicians should be aware of this phenomenon and take care to distinguish it from a true-positive response during C-PD, as defined by the SIS guidelines. Misinterpretation of the Startle Response as a positive C-PD result may lead to inappropriate future care decisions in a substantial proportion of patients.

The Effectiveness of Cervical Medial Branch Radiofrequency Ablation for Chronic Facet Joint Syndrome in Patients Selected by a Practical Medial Branch Block Paradigm

Background Cervical medial branch radiofrequency ablation (CMBRFA) is an effective treatment for facetogenic pain in patients selected by Spine Intervention Society (SIS) guidelines of 100% symptom improvement with dual medial branch blocks (MBBs) ± placebo block. Patient selection for CMBRFA using ≥80% symptom improvement after dual concordant MBBs is common; however, this has not been studied. Objective To evaluate the effectiveness of CMBRFA and compare outcomes in individuals selected by 80–99% vs 100% symptom improvement with dual concordant MBBs. Design Cross-sectional cohort study. Methods Medical records of 87 consecutive patients were reviewed; 50 met inclusion criteria. A standardized telephone survey was performed at six or more months post-CMBRFA to query numerical rating scale (NRS) pain and patient global impression of change (PGIC) scores. The primary outcomes were the proportion of patients reporting ≥50% reduction of index pain. Results At a mean follow-up time of 16.9 ± 12.7 months, 54% (95% confidence interval [CI] = 35–73%) and 54% (95% CI = 32–74%) of the 80–99% and 100% MBBs groups, respectively, reported ≥50% pain reduction. Between-group comparison showed a relative risk of 0.99 (95% CI = 0.59–1.66) for meeting the primary outcome. Seventy percent (95% CI = 56–81%) of patients reported a PGIC score consistent with “improved or very much improved” at follow-up. Conclusions CMBRFA is an effective treatment in patients who report ≥80% symptom relief with dual concordant MBBs. The present study demonstrated an overall ≥50% pain reduction rate of 54% and no significant difference between those selected by 80–99% vs 100% symptom relief with dual concordant MBBs.