Management of hangman's fractures using anchored anterior cervical cages.

Background: Hangman's fractures comprise approximately 20% of C2 fractures and often require surgery to correct significant angulation and/or subluxation. Recently, anchored anterior cervical cages (ACCs) have been used to fuse C2-3 as they reduce the risks of soft-tissue dissection, bone drilling, operative time, and postoperative dysphagia. Methods: This single-center and retrospective study (2012-2019) included 12 patients (3 type I, 6 type II, and 3 type IIa fractures) undergoing C2-3 ACCs (zero profile, half plate, full plate). Preoperative and postoperative radiographic and clinical data were analyzed. Results: The 12 patients demonstrated the following findings: a mean operative time of 106 ± 21 min, blood loss averaging 67 ± 58 mL, and mean length of stay of 9.8 ± 7.7 days (6.4 ± 5.5 days in intensive care). The mean differences in preoperative versus postoperative radiographs showed an increase in disc angle (9.0° ± 9.4° vs. 14.0° ± 7.2°), reduction of subluxation (18.5% ± 13.6% vs. 2.6% ± 6.2%), and maintenance of C2-7 lordosis (14.3° ± 9.5° vs. 14.4° ± 9.5°). All patients demonstrated fusion on dynamic films obtained >6 months postoperatively. In addition, only one patient had Grade 0 subsidence, three had transient postoperative dysphagia, whereas none had either intraoperative complications or 90-day readmissions. Conclusion: ACCs proved to be a viable alternative to traditional anterior cervical discectomy/fusion to treat 12 patients with C2-3 hangman's fractures in this preliminary study.

Pathoanatomy, biomechanics, and treatment of upper cervical ligamentous instability: A literature review.

Background: Cervical spine instability broadly refers to compromise of the articular congruity. It can be stratified according to spinal level, functional compromise, and mechanism of instability. Conventional wisdom advocates for use of bracing and physical therapy with only a subset of patients proceeding to obtain surgical treatment. Objective: The purpose of this review article is to summarize the current state of knowledge on upper cervical ligamentous instability. Methods: The literature search was performed in Mendeley. Search fields were varied until redundant. All articles were screened by title and abstract and a preliminary decision to include an article was made. The full-text screening was performed on the selected articles. Any question regarding the inclusion of an article was discussed by 3 authors until an agreement was reached. Results: Many articles report on the etiological factors including ligamentous laxity, traumatic injury, syndrome instability, iatrogenic instability, congenital, and inflammatory causes. A few recent studies elucidate new findings regarding pathoanatomy through the use of finite element analysis. A few articles demonstrate the diagnosis and show that radiographs alone have a low diagnostic rate and that functional MRI may be able to better quantify instability. Conservative treatment has been described, but there are no outcome studies in the literature. Surgical treatment has been described in many different populations with good radiologic and clinical outcomes. Recently the use of preoperative 3D CT reconstruction has been described with radiographic and immediate postoperative patient-reported outcomes. Conclusion: The presentation of upper cervical spinal instability can be asymptomatic, symptoms of isolated instability, symptoms of nerve irritation, vertebrobasilar insufficiency, or severe neurologic compromise. 3D fine element analysis models and motion-capture systems have the potential to increase our understanding of the pathoanatomic cascade in both traumatic and non-traumatic cases of upper cervical spinal instability. A few modalities on the horizon could increase diagnostic potential. More efforts are needed regarding the use of fine element analysis in understanding the pathoanatomic cascade, the long-term outcomes of children over a spectrum of syndromic causes, and the potential of preoperative virtual simulation to improve surgical outcomes.

Skeletal Sarcomas: Diagnosis, Treatment, and Follow-up from the Orthopedic Oncologist Perspective.

This article focuses on skeletal sarcomas, a group of rare, heterogenous malignant tumors. We present information on the multi-disciplinary approach to the diagnosis, staging, treatment, and surveillance of these complex tumors that are critical to enhancing function and improving survival.

Defining the Learning Curve of Anterior Total Hip Arthroplasty After Fellowship-specific Training.

PURPOSE: To investigate the learning curve associated with performing direct anterior total hip arthroplasty (THA) immediately after fellowship training in this approach. METHODS: This was a multicenter, retrospective study that collected data on all direct anterior THAs performed by four fellowship-trained arthroplasty surgeons in their first year of practice. Demographic data, surgical time, blood loss, surgical complications, and medical complications were recorded. Regression models were created to evaluate the outcomes of interest. A generalized linear mixed model was used to estimate the effect of the number of THA procedures performed, a proxy for surgical experience with this procedure, on the variables of interest. RESULTS: A total of 286 patients undergoing direct anterior THA were included in this study. A decrease in surgical complications after approximately 40 cases and a decrease in medical complications at 25 to 50 cases were observed. Both surgical time and blood loss showed no learning curve. CONCLUSION: Extensive training with a direct anterior approach during fellowship minimizes the learning curve for blood loss and surgical time, but it continues to exist regarding perioperative surgical and medical complications. Recent fellowship graduates should be cautious and expect a learning curve of around 40 cases before complication rates begin to normalize.

Etiology Diagnosis and Management of Radial Nerve Entrapment.

CONTEXT: The anatomy of the radial nerve is prone to entrapment, each with different symptomology. Compression of entrapment of the radial nerve can occur near the radiocapitellar joint, the spiral groove, the arcade of Frohse, the tendon of the extensor carpi radialis brevis (ECRB), and at the radial tunnel. Those who require repetitive motions are at increased risk of peripheral neuropathy syndromes, including repetitive pronation and supination, trauma, or systemic disease; however, t the influence of all risk factors is not well understood. Depending on the location of entrapment, radial nerve entrapment syndrome presents different symptoms. It may include both a motor component and a sensory component. The motor component includes a dropped arm, and the sensory component can include pain and paresthesia in the distribution of the radial nerve that resolves with rest and exacerbates by repetitive pronation and supination. EVIDENCE ACQUISITION: Diagnostic evaluation for radial nerve entrapment, apart from clinical symptoms and physical exam, includes electromyography, nerve conduction studies, ultrasonography, and magnetic resonance imaging. Conservative management for radial nerve entrapment includes oral anti-inflammatory medications, activity modification, and splinting. Some recently performed studies mentioned promising minimally invasive techniques, including corticosteroid injections, peripheral nerve stimulation, and pulsed radiofrequency. RESULTS: When minimally invasive techniques fail, open or endoscopic surgery can be performed to release the nerve. CONCLUSIONS: Endoscopic surgery has the benefit of decreasing incision size and reducing time to functional recovery.

Surgical and Non-surgical Treatment Options for Piriformis Syndrome: A Literature Review.

CONTEXT: Piriformis syndrome is a solely clinical diagnosis that often eludes the practitioner and goes underdiagnosed. PS is a pain syndrome and for those it affects, causes persistent pain and limits daily activity and work capacity. It is a form of deep gluteal syndrome that needs to be considered on the differential of low back pain as it comprises between 0.3% - 6% of all low back pain cases and is frequently underdiagnosed. Piriformis syndrome may be primary due anatomic anomalies or secondary, though the majority of cases are secondary to some insult. The objective of this manuscript is to provide a description of the epidemiology and presentation of piriformis as well as both non-operative and operative treatment options. We review all of the recent clinical evidence regarding the aforementioned therapies. EVIDENCE ACQUISITION: Literature searches were performed using the below MeSH Terms using Mendeley version 1.19.4. Search fields were varied until further searches revealed no new articles. All articles were screened by title and abstract. Decision was made to include an article based on its relevance and the list of final articles was approved three of the authors. This included reading the entirety of the article. Any question regarding the inclusion of an article was discussed by all authors until an agreement was reached. RESULTS: Medical management and physical therapy show some promise; however, when conservative treatment fails minimally invasive methods such as steroid injections, botulinum toxin injections, dry needling are all efficacious and there is substantial clinical evidence regarding these therapies. In those patients in which minimally invasive techniques do not result in an adequate relief of pain and return of function, endoscopic release can be considered. Endoscopic release is far superior to open release of the piriformis syndrome given the higher success and lower rate of complications. CONCLUSIONS: Piriformis syndrome is an important differential diagnosis in the work up of lower back pain and should not be ruled out with proper examination and testing. Clinicians should consider medical management and conservative management in the initial treatment plan for piriformis syndrome. There are many options within the conservative management and the literature shows much promise regarding these. Physical therapy, steroid injections, botulinum toxin injections, and dry needling are all potentially effective therapies with few adverse effects. Surgical options remain as gold standard, but only when conservative management has failed and the symptoms are significant to affect daily living activities. Endoscopic decompression of the sciatic nerve with or without release of the piriformis muscle has a reported high likelihood of success and a low complication rate. Current literature supports the preference of the endoscopic approach over the open approach due to improved outcomes and decreased complications. Further research is to well define the metrics for the diagnosis of piriformis syndrome and may include a need to develop diagnostic criteria.

Naldemedine for the Use of Management of Opioid Induced Constipation.

Purpose of Review: Opioid medications are a pillar of acute and chronic analgesia, though their use is often accompanied by side-effects, such as opioid-induced constipation. Unfortunately, tolerance rarely develops to this untoward side effect. This review presents the background, evidence, and indications for the use of Naldemedine (Brand name Symproic 0.2 mg tablets) to treat opioid-induced constipation. Recent Findings: Opioids are often used for the treatment of acute and chronic analgesia. Outside of the central effect they exert, they also interact with peripheral receptors, resulting in opioid-induced constipation, the commonest of side effects of chronic opioid usage. Complications include colonic distention, ileus, perforation, and can progress to other serious bowel complications, which can result in hospitalization and fatal events.For the most part, laxatives and other anti-constipation therapies are often inefficient and require intervention directed at the root cause, such as peripheral mu receptor agonists, including methylnaltrexone, naloxegol, and naldemedine. Naldemedine is the most recent to gain FDA approval of the group.An antagonist of Mu, Kappa, and Delta peripheral receptors, Naldemedine, is the only drug to counteract all three receptor classes. It was shown to be both safe and effective when compared with placebo. No data exists to compare its efficacy to that of other members of the group. Summary: Opioids are frequently used in the management of acute and chronic pain. The most common of the side effects is opioid-induced constipation, secondary to the peripheral activity of opioids. Naldemedine is an FDA-approved, once-daily oral tablet that counteracts this side effect by antagonizing mu, kappa, and delta-opioid receptors and has been shown to be safe and effective. Further investigation including head-to-head clinical trials are required to evaluate the relative efficacy of naldemedine compare with other peripheral opiate receptor antagonists.

Treatment and management of myofascial pain syndrome.

Myofascial Pain Syndrome (MPS) is a regional pain disorder that affects every age-group and is characterized by the presence of trigger points (TrPs) within muscles or fascia. MPS is typically diagnosed via physical exam, and the general agreement for diagnostic criteria includes the presence of TrPs, pain upon palpation, a referred pain pattern, and a local twitch response. The prevalence of MPS among patients presenting to medical clinics due to pain ranges anywhere from 30 to 93%. This may be due to the lack of clear criteria and guidelines in diagnosing MPS. Despite the prevalence of MPS, its pathophysiology remains incompletely understood. There are many different ways to manage and treat MPS. Some include exercise, TrP injections, medications, and other alternative therapies. More research is needed to form uniformly-accepted diagnostic criteria and treatments.