Transverse plane ultrasound-guided caudal epidural injections: sonographic anatomy and stepwise technique.

PURPOSE: The present study aims to provide a step-by-step procedural and anatomical familiarization guide for transverse plane ultrasound (US)-guided caudal epidural (CE) injection. METHODS: The study cohort consisted of 23 chronic low back pain patients (23-67 years old) previously unresponsive to conservative management. A transverse plane US-guided CE injection was performed, with each procedure step documenting and emphasizing sonographic anatomy. Several Thiel's method fixed cadaveric specimen dissections were also performed to demonstrate relevant CE injection-related anatomy. RESULTS: The sacral hiatus location can be estimated by visually forming an equilateral triangle between the posterior superior iliac spines and the sacral apex (trigonum sacrale). Follow-up palpation locates the sacral cornua, guiding transducer placement visualizing over the paired cornua 'bull frog's eye's appearance, with the epidural space visualized as a hypoechoic line, between the eyes. Then, 2-3 ml of 1% lidocaine is injected subcutaneously at the mid-point between the sacral cornua and superficial to the posterior sacrococcygeal ligament (SCL). Although keeping the cornua, superficial posterior SCL and epidural space in view, the needle is slowly advanced to the epidural space at around a 20 degree cephalad angle till the tip becomes visible. Expansion of the epidural space is monitored under the transverse sacral ligament as the injectant is slowly introduced. CONCLUSION: The present study demonstrated the anatomical landmarks necessary for the transverse ultrasound caudal epidural technique and that the cornua, superficial posterior SCL, CE space, and other relevant sacral hiatal anatomy are well visualized with this technique.

Femoral and tibial stress fractures associated with vitamin D insufficiency.

We describe a case highlighting the need to consider hypovitaminosis-D when investigating background causation and treatment of femoral and tibial stress fractures. The case also suggests that prescribing calcium and vitamin D supplementation may help with fracture healing in soldiers presenting with stress fractures who may have unrecognised hypovitaminosis-D which if left untreated may delay fracture healing.

Effects of biomechanical parameters of spinal manipulation: A critical literature review.

Spinal manipulation is a manual treatment technique that delivers a thrust, using specific biomechanical parameters to exert its therapeutic effects. These parameters have been shown to have a unique dose-response relationship with the physiological responses of the therapy. So far, however, there has not been a unified approach to standardize these biomechanical characteristics. In fact, it is still undetermined how they affect the observed clinical outcomes of spinal manipulation. This study, therefore, reviewed the current body of literature to explore these dosage parameters and evaluate their significance, with respect to physiological and clinical outcomes. From the experimental studies reviewed herein, it is evident that the modulation of manipulation's biomechanical parameters elicits transient physiological responses, including changes in neuronal activity, electromyographic responses, spinal stiffness, muscle spindle responses, paraspinal muscle activity, vertebral displacement, and segmental and intersegmental acceleration responses. However, to date, there have been few clinical trials that tested the therapeutic relevance of these changes. In addition, there were some inherent limitations in both human and animal models due to the use of mechanical devices to apply the thrust. Future studies evaluating the effects of varying biomechanical parameters of spinal manipulation should include clinicians to deliver the therapy in order to explore the true clinical significance of the dose-response relationship.

Radiofrequency Treatment of Iliac and Paravertebral Cluneal Nerves for Low Back Pain.

BACKGROUND: Paravertebral cluneal nerves are constrained within a tunnel consisting of the thoracolumbar fascia and the iliac crest's superior rim as they pass over the iliac crest. Their involvement in low back pain has not been presented previously. OBJECTIVE: To develop a diagnostic and therapeutic protocol for radiofrequency ablation of paravertebral and iliac cluneal trigger points. STUDY DESIGN: In a prospective observational cohort study, clinically painful trigger points were anatomically defined with diagnostic local anesthetic injections containing a steroid. Validated trigger points were ablated and the resolution of low back pain was monitored and analyzed. SETTING: The Spinal Foundation, The Weymouth Hospital, London, United Kingdom. METHODS: Injections at painful trigger points were considered diagnostic if patients reported 50% or more low back pain relief sustained for 10 days or more. These patients were treated with aware state radiofrequency ablation of the trigger points if the back or referred pain remained refractory despite 3 months of core correction physiotherapy. Clinical outcomes were assessed with the visual analog scale (VAS) and Oswestry Disability Index (ODI) scores for low back pain at a minimum follow-up of 2 years. RESULTS: This prospective feasibility study included 52 patients with an average age of 56.9 ± 14.9 years ranging from 29 to 83. The mean follow-up was 38.33 months ranging from 25 to 66 months. The average symptom duration before the first consultation was 54.8 months. Many patients had multiple failed chronic pain management interventions, including failed epidural steroid injections (28/52, 53.8%); failed facet injections (45/52, 86.5%); failed facet rhizotomies (20/52, 38.5%); and failed sacroiliac joint ablations (34/52, 65/4%). The majority had had spine surgery before presenting with persistent low back or radiating pain. The surgeries were microdiscectomy (38.5%), laminectomy (11.5%), laminotomy (3.8%), endoscopic transforaminal decompression (9.6%), foraminoplasty (1.9%), sacroiliac joint fusion (11.5%), total disc replacement (13.5%), and lumbar fusion (34.6%). Chief concerns were low back (69.2%), buttock pain (71.2%), groin pain (40.4%), trochanteric pain (28.8%), abdominal or flank pain (5.8%), anterior thigh pain (32.7%), and symptoms mimicking sciatica (19.2%). Validated painful trigger points were the lateral (5.7%), superior (48.1%), medial (23.1%), or a combination of 2 (23.1%). The VAS reduction was from 7.25 ± 1.79 to 1.11 ± 0.98 (P < 0.0001). The ODI reduction was from 51.23 ± 9.58 to 7.11 ± 6.69 (P < 0.001). The Prolo score was reduced from 3.59 ± 0.72 to 1.35 ± 0.59. Symptoms resolved completely in 34 (65.4%) patients but persisted slightly in 9 (17.3%) and mildly in another 8 (15.4%). There were no cases of infection, dysesthesia, numbness, or paralysis. LIMITATIONS: Our study suffers from low patient numbers and the absence of another diagnostic test definitively confirming the presence of painful cluneal nerve involvement. CONCLUSION: Cluneal trigger points should be considered in the differential diagnosis of pain in the lower back, flank, lower abdominal, buttock, trochanteric, groin, and thigh area. It is one form of so-called "pseudo-sciatica." The authors' diagnostic injection protocol suggests that most patients with cluneal trigger points may successfully be treated with percutaneous radiofrequency ablation.

Charcot arthropathy: The diagnostic dilemma of a painless, destructive joint.

The impressive clinical picture of Charcot joint reflects a high energy trauma injury which in the contrary is a progressive, painless arthropathy. Early and accurate diagnosis is crucial. A favorable outcome is elicited when joint is treated promptly, while late or misdiagnosis may lead to amputation.

Spinal manipulation therapy: Is it all about the brain? A current review of the neurophysiological effects of manipulation.

Spinal manipulation has been an effective intervention for the management of various musculoskeletal disorders. However, the mechanisms underlying the pain modulatory effects of spinal manipulation remain elusive. Although both biomechanical and neurophysiological phenomena have been thought to play a role in the observed clinical effects of spinal manipulation, a growing number of recent studies have indicated peripheral, spinal and supraspinal mechanisms of manipulation and suggested that the improved clinical outcomes are largely of neurophysiological origin. In this article, we reviewed the relevance of various neurophysiological theories with respect to the findings of mechanistic studies that demonstrated neural responses following spinal manipulation. This article also discussed whether these neural responses are associated with the possible neurophysiological mechanisms of spinal manipulation. The body of literature reviewed herein suggested some clear neurophysiological changes following spinal manipulation, which include neural plastic changes, alteration in motor neuron excitability, increase in cortical drive and many more. However, the clinical relevance of these changes in relation to the mechanisms that underlie the effectiveness of spinal manipulation is still unclear. In addition, there were some major methodological flaws in many of the reviewed studies. Future mechanistic studies should have an appropriate study design and methodology and should plan for a long-term follow-up in order to determine the clinical significance of the neural responses evoked following spinal manipulation.

Occupational hand injuries: a current review of the prevalence and proposed prevention strategies for physical therapists and similar healthcare professionals.

Hand injury is the second most common work-related musculoskeletal injury among physical therapists (PTs) and other manual therapy professionals such as osteopaths, physiotherapists, chiropractors, acupuncturists and massage therapists. However, the nature and extent of this problem have not been fully explored yet. Therefore, the objective of this study was to review the existing literature published on the prevalence, risk factors, consequences, and prevention of hand injuries among PTs and similar healthcare professionals. The lifetime prevalence of hand injuries was about 15%-46%, and the annual prevalence was reported as 5%-30%. Thumb injuries were found to be the most prevalent of all injuries, accounting more than 50% of all hand-related problems. The most significant risk factors for job-related hand injuries were performing manual therapy techniques, repetitive workloads, treating many patients per day, continued work while injured or hurt, weakness of the thumb muscles, thumb hypermobility, and instability at the thumb joints. PTs reported modifying treatment technique, taking time off on sick leave, seeking intervention, shifting the specialty area, and decreasing patient contact hours as the major consequences of these injuries. The authors recommend that PTs should develop specific preventive strategies and put more emphasis on the use of aids and equipment to reduce the risk of an unnecessary injury.

Rotator cuff impingement associated with Type III acromial morphology in a young athlete-a case for early imaging.

Down-sloped or hooked acromion morphologies may cause bony encroachment on the soft tissues of the subacromial space, predisposing to shoulder impingement syndrome. Of the latter, a hooked or Type III acromion (T3A) has also been linked to rotator cuff (RC) pathology. However, as bony acromial impingement is typically thought to occur over the age of 40, its occurrence in younger shoulder athletes presenting with shoulder pain, impingement and RC pathology may be overlooked. This case serves to illustrate the occurrence of T3A in a younger shoulder athlete, and the importance of early imaging in achieving diagnostic accuracy. Appropriate surgical referrals are patients with subacromial impingement syndrome refractory to 3-6 months of appropriate conservative treatment. Surgery may be particularly beneficial in patients with a T3A.

Fixation failure in an isolated tibial eminence ACL traction avulsion fracture in a paratrooper: is there an association with vitamin D deficiency?

Tibial eminence avulsion fracture at the ACL footprint may be caused by high-energy forces such as a fall, in which the ACL ligament proves stronger than the forces that hold the bone together. For reasons of bone maturity however, tibial spine avulsion fractures where the ACL remains intact, typically occur in children but are rare in adults. This case demonstrates a rare type of adult tibial avulsion fracture with intact ACL and subsequent fragment fixation failure in which vitamin D deficiency may have been contributory. Because there is a high rate of inadequate vitamin D levels in patients undergoing orthopaedic surgery and a known impact on bone healing complications, post-operative bone fixation failure may also occur. This case report may therefore prompt further awareness for considering pre-surgical vitamin D deficiency screening in adults presenting with rare avulsion fractures, and may further demonstrate its impact on surgical outcomes.