Utility of Ultrasound for Imaging Osteophytes in Patients With Insertional Achilles Tendinopathy.

OBJECTIVES: To examine (1) the validity of ultrasound imaging to measure osteophytes and (2) the association between osteophytes and insertional Achilles tendinopathy (IAT). DESIGN: Case-control study. SETTING: Academic medical center. PARTICIPANTS: Persons with chronic unilateral IAT (n=20; mean age, 58.7±8.3y; 10 [50%] women) and age- and sex-matched controls (n=20; mean age, 57.4±9.8y; 10 [50%] women) participated in this case-control study (N=40). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Symptom severity was assessed using the Foot and Ankle Ability Measure, the Victorian Institute of Sport Assessment-Achilles questionnaire, and the numerical rating scale. Length of osteophytes was measured bilaterally in both groups using ultrasound imaging, as well as on the symptomatic side of the IAT group using radiography. The intraclass correlation coefficient was used to examine the agreement between ultrasound and radiograph measures. McNemar, Wilcoxon signed-rank, and Fisher exact tests were used to compare the frequency and length of osteophytes between sides and groups. Pearson correlation was used to examine the association between osteophyte length and symptom severity. RESULTS: There was good agreement (intraclass correlation coefficient, ≥.75) between ultrasound and radiograph osteophyte measures. There were no statistically significant differences (P>.05) in the frequency of osteophytes between sides or groups. Osteophytes were larger on the symptomatic side of the IAT group than on the asymptomatic side (P=.01) and on the left side of controls (P=.03). There was no association between osteophyte length and symptom severity. CONCLUSIONS: Ultrasound imaging is a valid measure of osteophyte length, which is associated with IAT. Although a larger osteophyte indicates tendinopathy, it does not indicate more severe IAT symptoms.

Factors Associated With Early Improvement in Low Back Pain After Total Hip Arthroplasty: A Multi-Center Prospective Cohort Analyses.

This study identified factors associated with an improvement in low back pain (LBP) at six-month follow-up after total hip arthroplasty (THA). Data from a national registry of 3054 patients were analyzed. Factors under analysis included demographics, comorbid conditions, operative and nonoperative joint pain severity, physical function, and mental health. Differences in these factors between patients with and without improvement in LBP were examined. Among patients reporting severe or moderate LBP preoperatively, 56% improved 6 months after surgery. Patients without improvement were more likely to be on Medicare, have a high school education or less, have household income less than $45,000 and have one or more comorbid conditions. Patients with improvement in LBP experienced more resolution of pain in both the operative and nonoperative hip.

Underutilization of worker's compensation insurance among professional orchestral musicians.

UNLABELLED: Orchestral musicians commonly have playing-related symptoms (PRS) but few use worker's compensation (WC) insurance for assessment and treatment. The purpose of this study was to examine the frequency of, and factors related to, filing a WC claim among musicians. METHODS: An online questionnaire was completed by 261 members of the International Conference of Symphony and Opera Musicians (ICSOM). The responses were analyzed to describe the frequency and type of injuries, perceived cause of PRS, and severity of injury in musicians who did and did not file a WC claim. RESULTS: Of the musicians, 93% reported PRS in the 12 months prior to the study. Only 9 musicians filed WC claims during their careers, and all claims were for upper extremity injuries. The most frequent reason for not filing a WC claim was insufficient severity. Yet among musicians describing their PRS as not severe enough for a WC claim, 47% had symptoms for >15 minutes after playing and 16% had symptoms that interfered with daily activities. CONCLUSION: These data suggest there is frequent under-reporting of injuries to WC among professional orchestral musicians. Although most musicians reported PRS that persisted after playing, the most common reason for not filing a WC claim was insufficient severity of symptoms perceived by the musicians. Future research should focus on clearly defining severity for PRS-related injuries and determining when treatment for overuse syndromes should be paid for through the WC system.

Phox2b expression in the aldosterone-sensitive HSD2 neurons of the NTS.

The transcription factor Phox2b is necessary for the development of the nucleus of the solitary tract (NTS). In this brainstem nucleus, Phox2b is expressed exclusively within a subpopulation of glutamatergic neurons. The present experiments in the adult rat were designed to test whether this subpopulation includes the aldosterone-sensitive NTS neurons, which express the enzyme 11-beta-hydroxysteroid dehydrogenase type 2 (HSD2). Nuclear Phox2b was found in virtually all the HSD2 neurons (95-99%, n = 6 cases). Unlike the activity-related transcription factor c-Fos, Phox2b expression in the HSD2 neurons was not influenced by dietary sodium deprivation. The ubiquitous expression of Phox2b by the HSD2 neurons suggests that they are developmentally related to other Phox2b-dependent neurons of the NTS and that they release the excitatory neurotransmitter glutamate. This finding also suggests that human Phox2b mutations, which cause the central congenital hypoventilation syndrome (CCHS, also known as Ondine's curse), may also produce deficits in central aldosterone signaling and appetitive or autonomic responses to sodium deficiency.

Combined Cubital and Carpal Tunnel Release Results in Symptom Resolution Outside of the Median or Ulnar Nerve Distributions.

BACKGROUND: Resolution of symptoms including pain, numbness, and tingling outside of the median nerve distribution has been shown to occur following carpal tunnel release. We hypothesized that a similar effect would be found after combined release of the ulnar nerve at the elbow with simultaneous release of the median nerve at the carpal tunnel. METHODS: 20 patients with combined cubital and carpal tunnel syndrome were prospectively enrolled. The upper extremity was divided into six zones and the location of pain, numbness, tingling, or strange sensations was recorded pre-operatively. Two-point discrimination, Semmes-Weinstein monofilament testing, and validated questionnaires were collected pre-operatively and at six-week follow-up. RESULTS: Probability of resolution was greater in the median nerve distribution than the ulnar nerve for numbness (71% vs. 43%), tingling (86% vs. 75%). Seventy percent of the cohort reported at least one extra-anatomic symptom pre-operatively, and greater than 80% of these resolved at early follow-up. There was a decrease in pain as measured by validated questionnaires. CONCLUSION: This study documents resolution of symptoms in both extra-ulnar and extra-median distributions after combined cubital and carpal tunnel release. Pre-operative patient counseling may therefore include the likelihood of symptomatic improvement in a non-expected nerve distribution after this procedure, assuming no other concomitant pathology which may cause persistent symptoms. Future studies could be directed at correlating pre-operative disease severity with probability of symptom resolution using a larger population.

Google Glass as an Alternative to Standard Fluoroscopic Visualization for Percutaneous Fixation of Hand Fractures: A Pilot Study.

This pilot study investigated the feasibility of Google Glass to assist visualization of fluoroscopic images during percutaneous pinning of hand fractures. Cadavers were used to compare total time to pin each fracture and total number of radiographs per fracture from a mini C-arm. A FluoroScan monitor was used for radiographic visualization compared to projecting the images in the Google Glass display. All outcome measures significantly improved for proximal phalanx fractures (127 versus 86 seconds, p = 0.017; 5.3 versus 2.2 images, p = 0.003), and fewer images were obtained during fixation of metacarpal fractures using Google Glass compared with traditional techniques (6.4 versus 3.6, p < 0.001). Typical FluoroScan monitor placement may require the surgeon to alter focus away from the operative field, whereas Google Glass allows constant attention directed toward the operative field.

Vertebral Artery Injury during Routine Posterior Cervical Exposure: Case Reports and Review of Literature.

Study Design Case series. Objective We report the unusual occurrence of vertebral artery injury (VAI) during routine posterior exposure of the cervical spine. The importance of preoperative planning to identify the course of the bilateral vertebral arteries during routine posterior cervical spine surgery is emphasized. Methods VAI is a rare but potentially devastating complication of cervical spinal surgery. Most reports of VAI are related to anterior surgical exposure or screw placement in the posterior cervical spine. VAI incurred during posterior cervical spinal exposure surgery is not adequately addressed in the existing literature. Two cases of VAI that occurred during routine posterior exposure of the cervical spine in the region of C2 are described. Results VAI was incurred unexpectedly in the region of the midportion of the posterior C1-C2 interval during the initial surgical exposure phase of the operation. An aberrant vertebral artery course in the V2 anatomical section in the region between C1 and C2 intervals was identified postoperatively in both patients. A literature review demonstrates a relatively high incidence of vertebral artery anomalies in the upper cervical spine; however, the literature is deficient in reporting vertebral artery injury in this region. Recommendations for preoperative vertebral artery imaging also remain unclear at this time. Conclusions Successful management of this unexpected complication was achieved in both cases. This case report and review of the literature highlights the importance of preoperative vertebral artery imaging and knowledge of the course of the vertebral arteries prior to planned routine posterior exposure of the upper cervical spine. In both cases, aberrancy of the vertebral artery was present and not investigated or detected preoperatively.

Prospective cohort study of symptom resolution outside of the ulnar nerve distribution following cubital tunnel release.

BACKGROUND: Resolution of symptoms including pain, numbness, and tingling outside of the median nerve distribution has been shown to occur following carpal tunnel release. We hypothesized that a similar effect would be found after release of the ulnar nerve at the elbow. METHODS: Twenty patients with isolated cubital tunnel syndrome were prospectively enrolled. The upper extremity was divided into six zones, and the location of pain, numbness, tingling, or strange sensations was recorded pre-operatively. Two-point discrimination, Semmes-Weinstein monofilament testing, and validated questionnaires were collected. The same data were collected at 6-week follow-up. Paired t tests or non-parametric Wilcoxon Signed-Rank tests were used where appropriate to examine for significant (p ≤ 0.05) changes between pre- and post-operative scores. RESULTS: Probability of resolution was greater outside of the ulnar nerve distribution than within at early follow-up. There was a decrease in pain, numbness, and tingling symptoms both within and outside the ulnar distribution after cubital tunnel release. There was a decrease in pain as measured by several validated questionnaires. CONCLUSION: This study documents resolution of symptoms in an extra-ulnar distribution after cubital tunnel release. Improvement in pain and function after cubital tunnel release may be associated with an improvement in symptoms both within and outside the ulnar nerve distribution. Future studies could be directed at correlating pre-operative disease severity with probability of extra-territorial symptom resolution using a larger sample population.

Ulnar neuropathy at the elbow: an evidence-based algorithm.

Ulnar neuropathy at the elbow is the second most common compression neuropathy of the upper extremity and poses a challenge for treating physicians. Lack of a standardized grading system, outcome measures, or surgical indications can make treatment decisions difficult to justify. Conclusions drawn from the available literature include similar rates of good to excellent outcomes for in situ decompression; transposition in the subcutaneous, submuscular, or intramuscular planes; and endoscopic decompression. Outcomes for revision surgery are generally less favorable. Development of standardized outcomes measures will be important in improving the quality and comparability of the literature on this subject.

Paraventricular hypothalamic nucleus: axonal projections to the brainstem.

The paraventricular hypothalamic nucleus (PVH) contains many neurons that innervate the brainstem, but information regarding their target sites remains incomplete. Here we labeled neurons in the rat PVH with an anterograde axonal tracer, Phaseolus vulgaris leucoagglutinin (PHAL), and studied their descending projections in reference to specific neuronal subpopulations throughout the brainstem. While many of their target sites were identified previously, numerous new observations were made. Major findings include: 1) In the midbrain, the PVH projects lightly to the ventral tegmental area, Edinger-Westphal nucleus, ventrolateral periaqueductal gray matter, reticular formation, pedunculopontine tegmental nucleus, and dorsal raphe nucleus. 2) In the dorsal pons, the PVH projects heavily to the pre-locus coeruleus, yet very little to the catecholamine neurons in the locus coeruleus, and selectively targets the viscerosensory subregions of the parabrachial nucleus. 3) In the ventral medulla, the superior salivatory nucleus, retrotrapezoid nucleus, compact and external formations of the nucleus ambiguous, A1 and caudal C1 catecholamine neurons, and caudal pressor area receive dense axonal projections, generally exceeding the PVH projection to the rostral C1 region. 4) The medial nucleus of the solitary tract (including A2 noradrenergic and aldosterone-sensitive neurons) receives the most extensive projections of the PVH, substantially more than the dorsal vagal nucleus or area postrema. Our findings suggest that the PVH may modulate a range of homeostatic functions, including cerebral and ocular blood flow, corneal and nasal hydration, ingestive behavior, sodium intake, and glucose metabolism, as well as cardiovascular, gastrointestinal, and respiratory activities.