Non-operative orthobiologic use for rotator cuff disorders and glenohumeral osteoarthritis: A systematic review.

BACKGROUND: Shoulder pain from rotator cuff pathology and glenohumeral osteoarthritis is a common entity encountered in musculoskeletal practices. Orthobiologic agents are being increasingly used as a treatment option and understanding their safety and efficacy is necessary. OBJECTIVE: To systematically evaluate the available evidence for orthobiologic use in rotator cuff and glenohumeral pathology. METHODS: A systematic review was undertaken following PRISMA guidelines. Randomized clinical trials (RCTs) and prospective cohort studies evaluating non-operative treatment with prolotherapy, platelet-rich plasma (PRP), or medicinal signaling cells (MSCs) for rotator cuff pathology and glenohumeral osteoarthritis were included. Bias risk assessments used were the Cochrane tool and Newcastle-Ottawa score. RESULTS: The search yielded 852 potential articles, of which 20 met the inclusion criteria with a breakdown of 5 prolotherapy, 13 PRP, and 2 MSC. Sixteen studies were RCTs and 4 were cohort studies. Six studies were deemed "low risk of bias or good quality". Efficacy results were mixed, and no serious adverse events were reported from orthobiologic treatment. CONCLUSIONS: Orthobiologics offer a relatively safe management option with inconclusive evidence for or against its use for rotator cuff pathology. No studies on glenohumeral osteoarthritis met the inclusion criteria. Adoption of standardized preparation reporting and consistent use of functional outcome measures is imperative for future studies to consider.

Telemedicine During COVID-19 for Outpatient Sports and Musculoskeletal Medicine Physicians.

INTRODUCTION: The global pandemic due to SARS-CoV-2 has resulted in an expansion of telemedicine. Measures of quality and barriers for rapid use by patients and physicians are not well described. OBJECTIVE: To describe results from a quality improvement initiative during a rapid adoptive phase of telemedicine during the pandemic. DESIGN: Patient and physician satisfaction with synchronous audiovisual telemedicine visits was measured during the early adoptive phase (6 April 2020-17 April 2020) within the division of sports medicine in an academic Physical Medicine and Rehabilitation (PM&R) department. Patients were invited to participate in a quality improvement initiative by completing an online survey at the end of a telemedicine visit. Physicians completed a separate survey. PRIMARY OUTCOME MEASURES: Patient measures included visit type, duration of encounter, quality, and satisfaction. Physicians reported on experiences performed telemedicine. RESULTS: Surveys were completed by 119 patients (293 telemedicine encounters, response rate 40.6%) and 14 physiatrists. Telemedicine was utilized primarily for follow-up visits (n = 74, 70.6%), and the most common duration was 15 to 29 minutes. Patients rated their telemedicine visit as "excellent" or "very good" across measures (91.6%-95.0%) including addressing concerns, communication, developing a treatment plan, convenience, and satisfaction. Value of completing a future telemedicine visit was measured at 84.9%. Most reported estimated travel time saved was in excess of 30 minutes. Rate of no-show was 2.7%. Most physicians (57.1%) had no prior experience with telemedicine visits, and most were comfortable performing these visits after completing 1 to 4 sessions (71%). Nearly all physicians (92.9%) rated their telemedicine experience as very good or excellent. The key barrier identified for telemedicine was technical issues. All physicians reported plans to perform telemedicine visits if reimbursement continues. CONCLUSIONS: In summary, rapid expansion of telemedicine during the COVID-19 pandemic was well-received by a majority of patients and physicians. This suggests feasibility in rapid expansion of telemedicine for other outpatient sports medicine practices.

Pain Reduction and Repeat Injections After Transforaminal Epidural Injection With Particulate Versus Nonparticulate Steroid for the Treatment of Chronic Painful Lumbosacral Radiculopathy.

BACKGROUND: The corticosteroid choice for a lumbar transforaminal epidural steroid injection (TFESI) remains controversial. Whether to utilize particulate or nonparticulate steroid preparations for these injections remains an unanswered question in the literature. OBJECTIVE: To determine if a particulate or nonparticulate steroid is more effective in the treatment of electromyography (EMG)-confirmed lumbosacral radiculopathy. DESIGN: Multicenter retrospective cohort study. SETTING: Two tertiary academic spine centers. PATIENTS: Consecutive patients, aged 18 years or older, with EMG-confirmed lumbosacral radiculopathy. INTERVENTIONS: TFESI with a particulate or nonparticulate steroid to treat radicular pain within 6 months of EMG. MAIN OUTCOME MEASURES: The primary outcome was the proportion of patients with ≥50% pain reduction on the numerical rating scale after TFESI. Secondary outcomes included mean numerical rating scale score reduction and number of repeat TFESIs. Short-term (<30 days) and intermediate (≥30 days) outcomes were compared between patients who received a TFESI with a particulate versus nonparticulate steroid. RESULTS: Seventy-eight patients, with an age ± standard deviation of 56 ± 16 years and a mean symptom duration of 49 ± 71 months, were included. Forty-one patients (52%) received dexamethasone, 23 (30%) received triamcinolone, and 14 (18%) received betamethasone. There was no statistically significant difference in the proportion of patients who reported ≥50% pain reduction between the particulate and nonparticulate groups at short-term follow-up (35%; 95% confidence interval [CI], 21-51 versus 28%; 95% CI, 13-43) or at intermediate follow-up (40%; 95% CI, 21-59 versus 39%; 95% CI, 19-59). There was no difference in the mean number of injections administered between groups at intermediate follow-up (P = .26). CONCLUSIONS: This study demonstrates no significant differences in pain reduction or the number of repeat injections with particulate compared with nonparticulate transforaminal epidural steroid injection in patients with EMG-confirmed painful lumbosacral radiculopathy. These findings suggest a new population for whom nonparticulate steroid appears to be an appropriate first-line therapy, although confirmation with a randomized study is needed. LEVEL OF EVIDENCE: III.

Does Electrodiagnostic Confirmation of Radiculopathy Predict Pain Reduction after Transforaminal Epidural Steroid Injection? A Multicenter Study.

OBJECTIVE: Minimal definitive literature identifies patients with radicular pain who would benefit most from epidural steroid injection (ESI). This study investigated if electromyographic (EMG) confirmation of radiculopathy with active or chronic denervation predicts a positive treatment outcome following ESI. DESIGN: Longitudinal cohort study of adults who underwent EMG and subsequent transforaminal ESI within 6 months. The proportion of individuals who experienced >50% pain relief and mean change in daily morphine equivalents (DME) were calculated. RESULTS: 170 individuals with respective mean (Standard Deviation) age and duration of symptoms of 55 (15) years and 36 (56) months were included. Mean time to <30 day and >30 day follow-up post-injection were 18 (6) and 99 (130) days, respectively. At >30 day follow-up, a larger proportion of EMG-confirmed individuals (37.7%) reported >50% pain reduction compared to EMG-negative individuals (17.8%) (p=0.03). This was significant for lumbosacral (40% vs. 15%, p=0.01) but not cervical symptoms (p>0.05). Mean decrease in DME at long-term follow-up in EMG-confirmed compared to EMG-negative individuals trended toward significance (-4 vs. -1, p=0.11). There was no significant relationship between myotomal spontaneous activity and pain or opioid use. CONCLUSIONS: Needle EMG predicts long-term pain reduction from transforaminal ESI in patients with lumbosacral radiculopathy, regardless of the presence of active denervation.

Cervical angina: an overlooked source of noncardiac chest pain.

Cervical angina has been widely reported as a cause of chest pain but remains underrecognized. This series demonstrates the varied clinical presentation of patients with cervical angina, the delay in diagnosis, and the extensive cardiac examinations patients with this condition typically undergo prior to a definitive diagnosis. Recognition of this condition in patients with acute chest pain requires a high index of suspicion and an awareness of the common presenting features and clinical findings of cervical angina.

A peculiar complication of suprapubic catheterization: recurrent ureteral obstruction and hydronephrosis.

CONTEXT: Suprapubic cystostomy (SPC) catheterization is a common and important technique for the management of vesicular drainage, especially in patients with neurogenic bladder. Some serious complications include bowel perforation and obstruction. FINDINGS: A 55-year-old man with C6 American Spinal Injury Association B tetraplegia and a urethral stricture requiring a chronic SPC was admitted for recurrent urosepsis. Computed tomography (CT) of the abdomen revealed severe right hydronephrosis and hydroureter due to obstruction of the right distal ureter by the SPC tip. The SPC (30 French/10-mm silicone catheter with a 10-ml balloon) was removed and replaced with a similar suprapubic catheter (30 French/10-mm silicone catheter with an 8-ml balloon). Symptoms recurred 2 months later and he was readmitted for urosepsis. CT of the abdomen again revealed severe right hydronephrosis and hydroureter due to obstruction of the right distal ureter by the SPC tip. The SPC was removed, and the patient was given a 14 French/4.67-mm urethral silicone catheter with a 5-ml balloon. Follow-up CT of the abdomen 2 months later showed complete resolution of the hydronephrosis and hydroureter. Of note, urodynamic studies 2 years earlier revealed an extremely small bladder with a capacity less than 20 ml. CONCLUSION: This case illustrates that obstruction of the ureter by the tip of an SPC can be a cause of recurrent hydronephrosis and urosepsis.