Frequency and Localization of Neuromas in Transtibial Residual Limbs.

OBJECTIVE: To describe the frequency and localization of neuromas in residual limbs of individuals with transtibial amputation using ultrasound imaging. DESIGN: Cross-sectional study. SETTING: Rehabilitation center research laboratory. PARTICIPANTS: Adults who have lived with a transtibial amputation for >12 months were recruited for this study. Participants were included regardless of the presence or absence of residual limb neuropathic pain. Twenty-three participants (24 transtibial residual limbs) with and without residual limb neuropathic pain were enrolled. The etiology of amputation of most participants was peripheral vascular disease and diabetes. INTERVENTION: A comprehensive history was collected and a musculoskeletal ultrasound assessment for the presence and location of neuromas in their residual limb was conducted. During the ultrasound evaluation, a sonopalpation Tinel test was performed by applying pressure on each neuroma with the probe. MAIN OUTCOME MEASURES: Number of neuromas and their localization in each residual limb examined. RESULTS: A total of 31 neuromas in the 24 transtibial residual limbs were identified by ultrasound imaging. The average number of neuromas per residual limb was 1.3. All the major peripheral nerves studied could present neuromas, with a predominance of the superficial fibular nerve within our sample. Thirty-five percent of all the neuromas were described as painful. CONCLUSIONS: The presence of terminal neuromas on surgically sectioned nerves in transtibial residual limbs is frequent. Seventy-nine percent of participants had at least one neuroma. Ultrasound imaging is clinically useful to identify neuromas. The evaluator can easily communicate with the patient to diagnose symptomatic neuromas.

Gadolinium enhancement in cervical dorsal roots in a patient with acute autonomic and sensory neuropathy: a case report.

BACKGROUND: We report an enhancement of the dorsal roots on gadolinium-enhanced cervical magnetic resonance imaging (MRI) in a patient with acute autonomic and sensory neuropathy (AASN). CASE PRESENTATION: A 38-year-old woman visited our university hospital for dizziness and fainting while rising from sitting or lying down and a tingling sensation in the whole body, including her limbs, torso, and abdomen, which was sustained for 15 days. The patient had hyperalgesia in nearly her entire body and slight motor weakness in her bilateral upper and lower limbs. Autonomic dysfunction was confirmed using autonomic testing. Furthermore, the nerve conduction study showed an absence of sensory nerve action potentials in all evaluated peripheral nerves. Cervical MRI was performed 18 days after dysautonomia onset. In the axial T1-gadolinum-enhanced MRIs, enhancement in cervical ventral and dorsal nerve roots and the posterior column of the spinal cord were observed, and the axial T2-weighted MRI showed high signal intensity in the posterior column of the cervical spinal cord. Considering the clinical, electrophysiological and imaging findings, the patient was diagnosed with AASN. A total dose of 90 g (2 g/kg) of intravenous immunoglobulin was administered over 5 days. At the follow-up at 4 years after AASN symptom onset, the hyperalgesia and orthostatic hypotension symptoms improved. However, her systolic blood pressure intermittently decreased to < 80 mmHg. CONCLUSION: Gadolinium-enhanced MRI may facilitate the accurate and prompt diagnosis of AASN.

Effect of Repetitive Transcranial Magnetic Stimulation on Post-stroke Dysphagia: A Meta-analysis of Stimulation Frequency, Stimulation Site, and Timing of Outcome Measurement.

Dysphagia is one of the most frequent sequelae of stroke. It can result in various complications such as malnutrition, dehydration, aspiration pneumonia, and poor rehabilitation outcomes. Repetitive transcranial magnetic stimulation (rTMS) has been reported to improve dysphagia after a stroke; however, effective treatment protocols have not been established yet. We evaluated the effect of the following rTMS parameters on post-stroke dysphagia: stimulation frequency [high frequency (≥ 3 Hz) or low frequency (1 Hz)] and stimulation site (ipsilesional or contralesional mylohyoid cortex). Outcomes were measured immediately, at 3 weeks, and at 4 weeks after the rTMS session. The PubMed, SCOPUS, Embase, and Cochrane Library databases were systematically searched for relevant studies published between January 01, 1980, and December 13, 2021. Randomized controlled trials on the effects of rTMS on post-stroke dysphagia were included. Six studies were finally included in the analysis. The selected studies included 158 patients (rTMS group: 81 patients; sham group: 77 patients). Regarding the effect of high-frequency rTMS on the ipsilesional cortex, the standardized swallowing assessment (SSA) scores showed significant improvement after rTMS sessions immediately and at 4 weeks [immediate: P = 0.02, standard mean difference (SMD) = - 0.61, 95% confidence interval (CI) = - 1.14 to - 0.08; 4 weeks: P = 0.006, SMD = - 0.74, 95% CI = - 1.27 to - 0.21]; however, there was no significant reduction in the Penetration-Aspiration Scale (PAS) scores between the rTMS and sham groups (immediate: P = 0.43, SMD = 0.25, 95% CI = - 0.36, 0.86; 3 weeks: P = 0.39, SMD = 0.37, 95% CI = - 0.47 to 1.22). After low-frequency rTMS on the ipsilesional cortex, a significantly greater improvement in the SSA scores was found in the rTMS group than in the sham group, both immediately and at 4 weeks after rTMS sessions (immediate: P = 0.03, SMD = - 0.59, 95% CI = - 1.12 to - 0.06; 4 weeks: P = 0.001, SMD = - 0.92, 95% CI = - 1.48 to - 0.37). In addition, immediately after the rTMS sessions, the PAS scores were significantly reduced in the rTMS group than in the sham group (P = 0.047, SMD = - 0.60, 95% CI = - 1.19 to - 0.01). However, at 4 weeks after rTMS sessions, there was no significant reduction in the PAS scores in the rTMS group compared to the sham group (P = 0.48, SMD = - 0.19, 95% CI = - 0.71 to 0.33). Both high-frequency rTMS of the ipsilesional cortex and low-frequency rTMS of the contralesional cortex improved some measurements of the swallowing function in stroke patients immediately and at 4 weeks after treatment.

Effect of lacertus fibrosus release on perineural pressure of the median nerve at the elbow: a cadaveric study.

PURPOSE: The lacertus fibrosus (or bicipital aponeurosis) is a potential site of proximal median neuropathy at the elbow. Lacertus syndrome with motor and/or sensory symptoms has been addressed with a minimally invasive surgical lacertus release. This study evaluates if a lacertus release alters the maximal perineural pressure (Pmax) of the median nerve at the level of the lacertus fibrosus during elbow flexion. METHODS: Seven upper limbs from four fresh cadavers were included. Perineural pressure of the median nerve at the level of the lacertus fibrosus was measured continuously during automated elbow flexions by the biceps brachii muscle. RESULTS: The mean Pmax before the lacertus release was significantly different than the mean Pmax after the lacertus release (669.15 mmHg vs 77.01 mmHg, p = 0.0180). The mean Pmax after the lacertus release decreased with an average 81.41%. CONCLUSION: A simple surgical release of the lacertus fibrosus significantly decreases the maximal perineural pressure of the median nerve at the level of the lacertus fibrosus during elbow flexion.

Cytomegalovirus lumbosacral polyradiculitis in patients with long-term use of an oral corticosteroid: a case report.

BACKGROUND: The long-term use of an oral corticosteroid suppresses immunity. Here, we describe a case involving a patient with weakness in the bilateral lower extremities due to cytomegalovirus (CMV) lumbosacral polyradiculitis. CASE PRESENTATION: A 64-year-old man visited a university hospital for symmetric motor weakness in both lower extremities (Medical Research Council grade: 2). Symptoms started 1 month before and gradually aggravated. The patient had been taking oral prednisolone for 10 years in order to control pain in multiple joints due to seronegative rheumatoid arthritis. He also had neuropathic pain on the entire right lower extremity and voiding difficulty. Gadolinium-enhanced magnetic resonance imaging revealed enhancement along the entire lumbosacral nerve roots. In the cerebrospinal fluid analysis (CSF), elevated white blood cell (WBC) count (19 cells/µL) and protein level (142.5 mg/dL) were observed. CMV detection by polymerase chain reaction (PCR) was positive. We diagnosed the patient as having lumbosacral polyradiculitis due to CMV. Ganciclovir (250 mg twice daily) was administered intravenously. Two months after initiating Ganciclovir, in the CSF analysis, CM detection by PCR was negative, and no WBC was found. CONCLUSION: We reported a patient who had symmetric motor weakness in the bilateral lower extremities induced by CMV lumbosacral polyradiculitis. Its occurrence seems to be related to immunosuppresion due to the long-term use of an oral corticosteroid. When a patient who is taking an oral corticosteroid shows motor weakness in the bilateral lower extremities, CMV lumbosacral polyradiculitis is one of the possible disorders to be differentiated.

Neuropathic pain due to compression of cervical medial branch by cervical Juxtafacet cyst: A case report.

In the current report, we describe an interesting case of cervical juxtafacet that developed outside the intervertebral foramen, compressing the cervical medial branch and causing neuropathic pain in the posterior inferior neck pain. A 61-year-old woman visited a local pain clinic due to neuropathic pain with a tingling and burning nature (numeric rating scale [NRS]: 5 out of 10) on the left posterior inferior neck area for 4 months. Paresthesia was observed in the left posterior inferior neck area. On cervical radiography, segmental instability was observed at the C3-4 and C4-5 levels. Moreover, on the magnetic resonance imaging (MRI) of the cervical spine, a cyst (size: 1.3 cm × 0.7 cm × 1 cm) was outside the intervertebral foramen, contacting the left C4-5 facet joint and left C5 articular pillar. We thought that the compression of the left C5 medial branch by the cyst could cause the patient's pain. We conducted computed tomography (CT)-guided percutaneous needle aspiration of a cervical juxtafacet cyst. An 18-gauge needle was advanced under the guidance of CT into the largest portion of the cyst through a posterolateral oblique approach. Gelatinous mucoid fluid (approximately 0.5 cc) was aspirated. Immediately after the aspiration, 80% of the patient's pain was disappeared, and dysesthesia was completely disappeared. At the 1-, 3-, and 6-month follow-ups, the patient reported slight pain (NRS: 1) on the left posterior inferior neck. Cervical juxtafacet cysts can develop outside of the intervertebral foramen and spinal canal. Percutaneous needle aspiration can be a useful therapeutic tool for the treatment of such cysts.

Deep Learning for Detecting Supraspinatus Calcific Tendinopathy on Ultrasound Images.

Background: The aim of the study was to evaluate the feasibility of convolutional neural network (CNN)-based deep learning (DL) algorithms to dichotomize shoulder ultrasound (US) images with or without supraspinatus calcific tendinopathy (SSCT). Methods: This was a retrospective study pertaining to US examinations that had been performed by 18 physiatrists with 3-20 years of experience. 133,619 US images from 7836 consecutive patients who had undergone shoulder US examinations between January 2017 and June 2019 were collected. Only images with longitudinal or transverse views of supraspinatus tendons (SSTs) were included. During the labeling process, two physiatrists with 6-and 10-year experience in musculoskeletal US independently classified the images as with or without SSCT. DenseNet-121, a pre-trained model in CNN, was used to develop a computer-aided system to identify US images of SSTs with and without calcifications. Testing accuracy, sensitivity, and specificity calculated from the confusion matrix was used to evaluate the models. Results: A total of 2462 images were used for developing the DL algorithm. The longitudinal-transverse model developed with a CNN-based DL algorithm was better for the diagnosis of SSCT when compared with the longitudinal and transverse models (accuracy: 91.32%, sensitivity: 87.89%, and specificity: 94.74%). Conclusion: The developed DL model as a computer-aided system can assist physicians in diagnosing SSCT during the US examination.

Use of Pulsed Radiofrequency for the Treatment of Discogenic Back Pain: A Narrative Review.

BACKGROUND: Low-back pain (LBP) is one of the most frequently reported symptoms of patients who visit pain clinics, and a significant proportion of them have discogenic pain. Pulsed radiofrequency (PRF) stimulation is an effective treatment for various types of pain. PURPOSE: We reviewed articles which investigated the effectiveness of intradiscal PRF for controlling discogenic LBP. METHODS AND MATERIALS: We searched PubMed for papers published prior to August 7, 2020, in which intradiscal PRF was used for treating discogenic LBP. The key search phrase was (intradiscal PRF) for identifying potentially relevant articles. We included articles in which intradiscal PRF was used for controlling LBP. Review articles were excluded. RESULTS: Nine publications were included in this review. Except for one study, all other studies showed positive therapeutic outcomes after treating discogenic LBP using intradiscal PRF. However, the quality of these studies was not high. CONCLUSIONS: This review showed that intradiscal PRF appears to be a helpful treatment method for patients with discogenic LBP. Our review provides insights into the degree of evidence of the therapeutic effects of intradiscal PRF for alleviating discogenic LBP. For confirmation of the effectiveness of intradiscal PRF on discogenic LBP, more high-quality studies are necessary.

Dancers' Perceptions of Accessibility and Quality of the Relationship with Healthcare Professionals in Quebec.

OBJECTIVE: To understand dancers' perception of accessibility to care and quality of the relationship with healthcare practitioners in Quebec; to identify the key elements of an optimal dancer-physician relationship; and to propose recommendations for improvement. METHODS: An online questionnaire consisting of multiple choice, "yes/no," and short answer questions was sent to professional dance organizations, companies, agencies, and schools in Quebec, Canada. Information regarding the dance artists' sociodemographics, dance background, dance-related injuries, and access to a primary care physician were collected. Experiences and expectations regarding the dancer-physician relationship were surveyed. One-way ANOVA analyses and Pearson correlations were performed to assess differences of perception between dancers' demographic characteristics and associations between the variables. RESULTS: Out of 161 participants, 144 met inclusion criteria, consisting of largely French-speaking females, North American or European decent, self-employed contemporary dancers with an average age of 33.13 ± 10.81 yrs. Dance artists sought medical care from osteopaths (47.9%) and physiotherapists (36.1%) more frequently than from physicians (8.3%). Fully employed dancers had more favorable perceptions of the dancer-physician relationship compared to self-employed dancers and those who had mixed streams of income. The perception of most participants was that physicians do not comprehend the unique dance-associated impacts on health (81.8%). The most important aspect affecting perception of the relationship with the physician was diagnostic acumen (41.3%). Most participants (79.0%) selected "works with other health professionals [...] and gives expert advice" as an important expectation from physicians. CONCLUSION: This research is the first investigation of the dancer-physician relationship in Quebec. It reveals a desire amongst the dance artist community to improve the dancer-physician relationship and the overall quality of their unique healthcare requirements.

Management of Hand Spasticity with Ultrasound-guided Ethyl Alcohol Injection to the Deep Branch of the Ulnar Nerve.

Patients with stroke commonly experience limb spasticity, which can prevent functional recovery and cause functional disability, due to muscle tightness and joint stiffness in the affected limb. Using the ability of ultrasound (US) to visualize nerves, we successfully performed US-guided neurolysis of the motor branch of the ulnar nerve in Guyon's canal, while avoiding injury of its sensory branch, in a 63-year-old woman with upper limb poststroke spasticity. We believe that our method has the merit of precluding the development of neuropathic pain, following injury to the sensory branch of the ulnar nerve. Moreover, our method reduces operation time and perioperative pain.

Injury of Corticospinal tract and Corticoreticular pathway caused by high-voltage electrical shock: a case report.

BACKGROUND: We imaged the corticospinal tract (CST) and corticoreticular pathway (CRP) using diffusion tensor tractography (DTT) to evaluate the cause of muscle weakness in a patient who was exposed to high-voltage electricity. CASE PRESENTATION: A 39-year-old man presented with quadriparesis after high-voltage electrical shock from power lines while working about 5.8 years ago. The electrical current entered through the left hand and exited through the occipital area of the head. The degree of weakness on bilateral upper and lower extremities was 3-4 on the Medical Research Council strength scale. Diffusion tensor imaging (DTI) was performed 5.8 years after onset. The CST and CRP were depicted by placing two regions of interest for each neural tract on the two-dimensional fractional anisotropy color map. DTT of the DTI scan showed that the bilateral CST and CRP were thinned compared to those of the healthy control subject. On the nerve conduction test, abnormal findings suggesting peripheral nerve lesion were not observed. Therefore, injury of bilateral CST and CRP seems to have contributed to our patient's weakness after the electrical shock. CONCLUSION: Depiction of neural tracts in the brain using DTT can assist in the accurate and detailed evaluation of the cause of neural deficit after electrical injury.

An unusual presentation of neuropathic pain following cervical spinal cord injury: a case report.

BACKGROUND: We report a patient with unusual occipital neuropathic pain (at-level neuropathic pain) due to a small central cervical spinal cord injury (SCI). CASE PRESENTATION: A 50-year-old man presented with severe bilateral occipital pain after falling from a height of 2 m, 2 weeks ago. The degree of pain was evaluated to be 9 out of 10 using the numeric rating scale (NRS). The nature of the pain was tingling, burning, and piercing, and hyperalgesia was present over the bilateral posterior head regions. Greater occipital nerve block with bupivacaine and dexamethasone was not effective. On axial T2-cervical magnetic resonance imaging (MRI), a focal high signal change was observed in the central portion of the spinal cord at the C2 level. We deliberated that the patient's pain was due to the SCI observed on MRI, and after administration of oral medications, the NRS pain score reduced from 9 to 2. CONCLUSIONS: Neuropathic pain caused by SCI varies according to the location and degree of injury of the pain-related neural tracts; therefore, clinicians should closely observe the pain patterns and findings on imaging in patients with SCI to determine the cause of pain accurately.

Accuracy of Ultrasound-Guided Pudendal Nerve Block in the Ischial Spine and Alcock's Canal Levels: A Cadaveric Study.

BACKGROUND: Blockade of the pudendal nerve (PN) using ultrasound (US) guidance has been described at the levels of the ischial spine and Alcock's canal. However, no study has been conducted to compare anatomical accuracy between different approaches in targeting the PN. OBJECTIVE: To investigate the accuracy of US-guided injection of the PN at the ischial spine and Alcock's canal levels. This study also compared the accuracy of the infiltrations by three sonographers with different levels of experience. SUBJECTS: Eight Thiel-embalmed cadavers (16 hemipelvises). METHODS: Three physiatrists trained in musculoskeletal US imaging with 12 years, five years, and one year of experience performed the injections. Each injected a 0.1-mL bolus of colored dye in both hemipelvises of each cadaver at the ischial spine and Alcock's canal levels under US guidance. Each cadaver received three injections per hemipelvis. The accuracy of the injection was determined following hemipelvis dissection by an anatomist. RESULTS: The injections were accurate 33 times out of the total 42 attempts, resulting in 78% accuracy. Sixteen out of 21 injections at the ischial spine level were on target (76% accuracy), while the approach at Alcock's canal level yielded 17 successful injections (81% accuracy). The difference between the approaches was not statistically significant. There was also no significant difference in accuracy between the operators. CONCLUSIONS: US-guided injection of the PN can be performed accurately at both the ischial spine and Alcock's canal levels. The difference between the approaches was not statistically significant.

Accuracy of unguided and ultrasound guided Coracohumeral ligament infiltrations - a feasibility cadaveric case series.

BACKGROUND: Coracohumeral ligament (CHL) thickening, contracture, and fibroplasia have been identified in glenohumeral idiopathic adhesive capsulitis (GHIAC). The CHL is the main structure responsible for the range of motion limitations. Favorable outcomes have been reported with CHL surgical release. Intra-articular glenohumeral joint corticosteroid infiltrations are utilized to disrupt the inflammatory process and reduce pain in GHIAC. The aim of this study was to investigate whether the CHL could be accurately targeted with a periligamentous infiltration. METHODS: A convenience sample of 12 unembalmed cadaver shoulders (mean age: 74.5 years, range 66-87 years) without evidence of previous injury or surgery were utilized in this exploratory double factor feasibility cadaveric (unguided and ultrasound (US) guided) case series. Two clinicians trained in musculoskeletal infiltration techniques carried out the infiltrations on each shoulder with colored latex. One clinician infiltrated without guidance, the other with US-guidance. The injecting clinicians were blinded to the others infiltration procedure and the order was randomized. An anatomist blinded to the infiltration order performed a shoulder dissection and recorded the infiltrate location. Percentage calculation for accuracy of infiltration and a chi-square evaluation of the difference between unguided and US-guided infiltrations was applied. RESULTS: An accuracy of 75% was achieved for unguided infiltration and 80% for US-guided infiltration techniques. Chi-squared indicated there was no significant difference (p = 0.82) between the unguided and US-guided techniques. CONCLUSION: US-guided and unguided infiltrations achieved good accuracy targeting the CHL, suggesting infiltrations can specifically and accurately target the CHL. In vivo investigation using such infiltration techniques are warranted.

Can repetitive transcranial magnetic stimulation enhance motor outcomes in cerebral infarct patients?

The effectiveness of repetitive transcranial magnetic stimulation on the post-stroke motor recovery is not apparent. To perform an accurate evaluation, we adjusted for critical factors that determine motor outcomes, including lesion location and the state of the corticospinal tract. We only included patients with cerebral infarct in the corona radiata and with corticospinal tract interruption, apparent on diffusion tensor tractography. We retrospectively enrolled 34 patients whose diffusion tensor tractography corticospinal tract was interrupted by a cerebral infarct. The corticospinal tract state of each patient was evaluated using diffusion tensor tractography. Of the 34 patients whose corticospinal tract was interrupted on diffusion tensor tractography, 12 patients underwent repetitive transcranial magnetic stimulation treatment at the early stage after cerebral infarct (repetitive transcranial magnetic stimulation group). In comparison, 22 patients did not receive repetitive transcranial magnetic stimulation treatment (non-repetitive transcranial magnetic stimulation group). High-frequency repetitive transcranial magnetic stimulation (10 Hz) was performed on the primary motor cortex of the affected hemisphere. At the six month evaluation after the onset of the infarct, motor function was measured in each patient. In both groups, compared to their states during the initial evaluation, significant improvement was found in all measurements of motor function. However, six months after onset, no significant differences between the two groups were found in these measurement scores. When a patient's CST is interrupted, high-frequency repetitive transcranial magnetic stimulation treatment at the early stage after cerebral infarct might have no additional therapeutic effect on motor outcome. Qualified randomized controlled trials are needed to support our findings further.

The Effectiveness of Pulsed Radiofrequency on Joint Pain: A Narrative Review.

BACKGROUND: Pulsed radiofrequency (PRF) stimulation has been safely and effectively applied for controlling various types of pain. PURPOSE: We reviewed the literature on the efficacy of PRF for controlling pain in joint disorders. METHODS: We searched PubMed for papers published prior to September 7, 2019, that used PRF to treat pain due to joint disorders. The key search phrases for identifying potentially relevant articles were (PRF AND joint) OR (PRF AND arthritis) OR (PRF AND arthropathy). The following inclusion criteria were applied for the selection of articles: (1) patients' pain was caused by joint disorders; (2) PRF stimulation was applied to manage joint-origin pain; and (3) after PRF stimulation, follow-up evaluation was performed to assess the reduction in pain intensity. Moreover, joints with more than 3 reported PRF studies were included in our review. RESULTS: The primary literature search yielded 141 relevant papers. After reading their titles and abstracts and assessing their eligibility based on the full-text articles, we finally included 34 publications in this review. Based on the positive therapeutic outcomes of previous studies, PRF stimulation seems to be an effective treatment for cervical and lumbar facet, sacroiliac, knee, and glenohumeral joint pain. PRF appears to be beneficial. For confirmation of the effectiveness of PRF on joint pain, more high-quality studies are needed. CONCLUSIONS: Our review provides insights on the degree of evidence according to pain in each joint, which will help clinicians make informed decisions for using PRF stimulation in various joint pain conditions.

An Unusual Volar Wrist Mass: Radial Artery Pseudoaneurysm Following Transradial Catheterization.

Arterial pseudoaneurysms can develop secondary to a vessel injury, for example, an arterial line installation. We present a case of an 18-year-old female with mitochondrial encephalopathy, lactic acidosis, and stroke-like episodes syndrome who developed left radial artery and right brachial artery pseudoaneurysms secondary to arterial line placement and repeated blood draws, respectively. The ultrasonographic features of pulsating mass in connection with an artery and the yin-yang sign, combined with the patient's history, allowed accurate diagnosis. She was referred to vascular surgery for definitive treatment.