Predicting Treatment Success with Facet Syndrome: An Algorithm to Predict Lumbar Radiofrequency Ablation Responders in a Military Population.

OBJECTIVE: Radiofrequency ablation (RFA) of the medial branch nerve is a commonly performed procedure for patients with facet syndrome. RFA has previously been demonstrated to provide long-term functional improvement in approximately 50% of patients, including those who had significant pain relief after diagnostic medial branch block. We sought to identify factors associated with success of RFA for facet pain. DESIGN: Active-duty military patients who underwent lumbar RFA (L3, L4, and L5 levels) over a 3-year period were analyzed. Defense and Veterans Pain Rating Scale (DVPRS) and Oswestry Disability Index (ODI) scores were assessed the day of procedure and at the 2-month and 6-month follow-up. These data were analyzed to identify associations between patient demographics, pain, and functional status and patients' improvement after RFA, with a primary outcome of ODI improvement and a secondary outcome of pain reduction. RESULTS: Higher levels of starting functional impairment (starting ODI scores of 42.9 vs. 37.5; P = 0.0304) were associated with a greater likelihood of improvement in functional status 6 months after RFA, and higher starting pain scores (DVPRS pain scores of 6.1 vs. 5.1; P < 0.0001) were associated with a higher likelihood that pain scores would improve 6 months after RFA. A multivariate logistic regression was then used to develop a scoring system to predict improvement after RFA. The scoring system generated a C-statistic of 0.764, with starting ODI, pain scores, and both gender and smoking history as independent variables. CONCLUSIONS: This algorithm compares favorably to that of diagnostic medial branch block in terms of prediction accuracy (C-statistic of 0.764 vs. 0.57), suggesting that its use may improve patient selection in patients who undergo RFA for facet syndrome.

Regional Anesthesia for Symptomatic Treatment of Stingray Envenomation.

Stingray envenomation is common in coastal regions around the world and may result in intense pain that can be challenging to manage. Described therapies involve hot water immersion and potentially other options such as opioid and nonopioid analgesics, removal of the foreign body, wound debridement, antibiotics for secondary infection, and tetanus toxoid. However, for some patients, this may not be enough. Peripheral nerve blockade is a frequently used perioperative analgesic technique, but it has rarely been described in the management of stingray envenomation. Here, we report a case of stingray envenomation in an otherwise healthy 36-y-old male with pain refractory to traditional therapies. After admission for pain control, the patient received an ultrasound-guided sciatic popliteal nerve block. Upon completion of the peripheral nerve block, the patient reported rapid and complete resolution of the intense pain, which did not return thereafter.

F/A-18 Aviator Successfully Returned to Flight After an In-Flight Spontaneous Pneumothorax.

BACKGROUND: Spontaneous pneumothorax (PTX) is a diagnostic challenge in aviators given the common occurrence of musculoskeletal pain after flight and notorious underreporting of symptoms of other diseases in this group.CASE REPORT: A 24-yr-old active duty F/A-18 Weapon Systems Officer performed an anti-G straining maneuver (AGSM) in response to a 6.5-g warm-up turn during a training flight at 16,000 ft (4876.8 m) above sea level. He immediately developed right-sided thoracic back pain. The flight was terminated, he landed, and the pain improved. Over the next 5 d, he noticed the insidious development of pleuritic chest pain and dyspnea. His symptoms prompted presentation to an aviation medicine clinic where a large right sided PTX was identified. After transfer to a local emergency department, a large bore chest tube was placed. A CT scan showed bilateral apical blebs requiring right and subsequently left video assisted thoracoscopy (VATS) with chemical/mechanical pleurodesis and apical wedge resection. Pulmonary function testing (PFT) showed a mild restriction defect 2-1/2 mo after surgery. The patient also completed cardiopulmonary exercise testing (CPET), performing better than his predicted reference range. After a high resolution CT showed no remaining signs of bleb or cyst disease and another month of healing he was returned to flight.DISCUSSION: PTX should be considered in aviators with perithoracic pain after flight as several aspects of flight in high performance aircraft may increase the risk for PTX. These include positive pressure breathing through a facemask, repeated use of the AGSM, and the possibility of bleb expansion at altitude.DeYoung H, Ahmed Y, Buckley J. F/A-18 aviator successfully returned to flight after an in-flight spontaneous pneumothorax. Aerosp Med Hum Perform. 2018; 89(11):1008-1012.

Successful treatment of community-acquired methicillin-resistant Staphylococcus aureus purulent myopericarditis.

A previously healthy 48-year-old active duty man, who had been treated for an elbow abscess 3 weeks earlier, presented to an emergency department in Bahrain with tachycardia, pericardial friction rub and jugular venous distention. Cardiac tamponade was confirmed on transthoracic echocardiogram and he was taken for emergent pericardiocentesis. Pericardial fluid cultures grew community-acquired methicillin-resistant Staphylococcus aureus Despite ongoing treatment with intravenous vancomycin, he developed a recurrent fibrinous pericardial effusion and constrictive pericarditis requiring pericardiectomy. Though he initially did well postoperatively, he developed drug reaction with eosinophilia and systemic symptoms syndrome in response to vancomycin. He was transitioned to ceftaroline and started on high-dose steroids. He recovered during a week-long admission and was discharged home. Several weeks later at follow-up he was doing well and had resumed moderate intensity exercise.