Ultrasound-guided diagnostic IPACK as a valuable tool in the management of a patient with soleal sling syndrome: a doubly rare case report.

This article describes the use of an infiltration between the popliteal artery and capsule of the knee joint (IPACK) to diagnose an entrapment neuropathy of the tibial nerve (TN) in a patient presenting with chronic neuropathic pain in the medial posterior compartment of the left knee, with a previous electromyography showing no evidence of tibial or common peroneal nerve neuropathy. After a positive sciatic nerve block, the patient was evaluated for a TN block, cancelled due to the presence of an abnormal leash of vessels wrapping around the nerve. For this reason, the patient was submitted to a diagnostic IPACK. A negative IPACK suggested that a compression of the TN at the popliteal fossa was the most likely source of the symptoms. After surgical decompression of the TN nerve at the popliteal fossa, the patient's symptoms decreased substantially.

Lay abstract This case report describes the use of an infiltration between the popliteal artery and capsule of the knee joint (IPACK), a technique in which local anesthetic is injected between the popliteal artery and the back side of the knee joint, to diagnose a compression of the tibial nerve (TN) in a patient with chronic knee pain. A female adult patient presented for further evaluation of chronic pain in the inner side of the back of her left knee. A previous electromyography showed no evidence of tibial or common peroneal nerve disease. After a positive diagnostic block of the left sciatic nerve, the patient was evaluated for a left TN block, so as to ascertain whether a compression of this nerve at the back side of the knee could be the origin of the patient's symptoms. During the ultrasound scanning of the TN, a group of abnormal vessels was found wrapping around the nerve, which made it impossible to inject the TN in a safe manner, even with the guidance of ultrasound. For this reason, the patient was instead submitted to a diagnostic left IPACK. A negative IPACK suggested that a compression of the TN at the popliteal fossa, the region behind the knee joint, was the most likely source of the patient's symptoms. After surgical decompression of the TN at the popliteal fossa, the patient's symptoms decreased substantially.

A Retrospective Cohort Study of Healthcare Utilization Associated with Paravertebral Blocks for Chronic Pain Management in Ontario.

Background: Injections, particularly paravertebral blocks (PVBs), are frequently performed procedures in Ontario, Canada, for the management of chronic pain, despite limited evidence and risk of complications. Aim: This study examines usage patterns of PVBs to evaluate their effects on healthcare utilization and opioid prescribing. Methods: A retrospective cohort study in Ontario using administrative data. Ontario residents receiving their initial PVBs between July 1, 2013 and March 31, 2018 were included. Changes in use of other interventions, physician visits, and opioids were compared to the 12-month periods before and after index PVBs. Data use was authorized under section 45 of Ontario's Personal Health Information Protection Act. Results: 47,723 patients received their initial PVBs in the study period. The rate of index PVBs increased from 1.61 per 10,000 population (2013) to 2.26 per 10,000 (2018). Initial PVBs were performed most commonly by family physicians (N = 25,042), followed by anesthesiologists (N = 14,195). 23,386 patients (49%) received 1 to 9 repeat PVBs in the 12 months after index PVB; 12,474 patients (26.15%) received 10 or more. Use of other nonimage guided interventional pain procedures per patient (mean±SD) increased from 2.19 ± 9.35 to 31.68 ± 52.26 in the year before and after index PVB. Relevant physician visits per patient (mean±SD) also increased from 2.92 ± 3.61 to 9.64 ± 11.77. Mean opioid dosing did not change significantly between the year before and the year after index PVB. Conclusion: PVBs are associated with increases in healthcare utilization and no change in opioid use patterns.

Contexte: Les injections, en particulier les blocs paravertébraux (BPV), sont des procédures fréquemment effectuées en Ontario, Canada, pour la prise en charge de la douleur chronique, malgré des données probantes limitées et le risque de complications.Objectif: Cette étude examine les modes d'utilisation des BPV afin d'évaluer leurs effets sur l'utilisation des soins de santé et la prescription d'opioïdes.Méthodes: Étude de cohorte rétrospective utilisant les données administratives en Ontario. Les résidents de l'Ontario ayant reçu leur BPV initial entre le 1er juillet 2013 et le 31 mars 2018 ont été inclus. Les changements dans l'utilisation des autres interventions, les visites aux médecins et les opioïdes ont été comparés 12 mois avant et 12 mois après les BPV de référence. L'utilisation des données a été autorisée en vertu de la Loi sur la protection des renseignements personnels sur la santé de l'Ontario.Résultats: 47 723 patients ont reçu leur BPV initial au cours de la période étudiée. Le taux de BPV est passé de 1,61 pour 10 000 habitants (2013) à 2,26 pour 10 000 (2018). Les BPV de référence étaient effectués le plus souvent par des médecins de famille (N = 25 042), suivis par les anesthésistes (N = 14 195). 23 386 patients (49 %) ont reçu de 1 à 9 BPV répétés dans les 12 mois suivant le BPV de référence ; 12 474 patients (26,15 %) en ont reçu 10 ou plus. L'utilisation d'autres procédures interventionnelles pour la douleur non guidées par l'image par patient (moyenne ± ET) est passée de 2,19 ± 9,35 à 31,68 ± 52,26 l'année précédant et suivant le BPV. Les visites médicales pertinentes par patient (moyenne ± ET) ont également augmenté de 2,92 ± 3,61 à 9,64 ± 11,77. La dose moyenne d'opioïdes n'a pas changé de manière significative entre l'année précédant et suivant le BPV de référence.Conclusion: Les BPV sont associés à une augmentation de l'utilisation des soins de santé et ne sont associés à aucun changement dans les modes d'utilisation des opioïdes.

The architecture of the 6-month-old gastrocnemius: a 3D volumetric study

Gastrocnemius is essential in normal gait, contributing to the control of ankle plantar flexion and knee flexion. However, there is a paucity of literature on the architecture of the infant gastrocnemius muscle prior to the onset of weight-bearing and gait. This study investigates the three-dimensional (3D) musculoaponeurotic architecture of the gastrocnemius in a six-month-old infant. One six-month-old cadaver was used in this study (The University of Toronto Health Sciences Research Ethics Board, #32679, and The University of Auckland Human Participants Ethics Committee, #016164). Medial (MG) and lateral (LG) heads of the gastrocnemius were serially dissected and a Microscribe G2X(TM) digitizer used to digitize fiber bundles, aponeuroses and tendons. Data were then exported to Autodesk(R) Maya(R) to create 3D models. Custom software quantified architectural parameters, including fiber bundle length, pennation angle, physiological cross-sectional area, and muscle volume. The intramuscular architecture was assessed to determine whether musculoapo-neurotic partitions were present. Muscle volume was <1cm3 for both MG and LG. Three architectural partitions, proximal, middle, and distal, were identified for both MG and LG. Notably, the proximal partitions of both MG and LG had mean fiber bundle length at 2.21 ± 0.41 cm and 2.22 ± 0.27 cm, significantly greater (p < 0.05) than the middle and the distal partitions. The results of this study suggest that both MG and LG have architectural partitions before the commencement of gait. Further longitudinal studies with larger sample sizes are needed to confirm the presence of these architectural partitions, as well as to investigate their growth across the developmental spectrum

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