Adverse Events of the Long-Term Use of Opioids for Chronic Non-cancer Pain: A Narrative Review.

BACKGROUND: The long-term use of opioids for chronic non-cancer pain (CNCP) has drawn more attention and debate. Although opioids are frequently used to treat chronic pain, their effectiveness and safety over extended periods are still unknown. OBJECTIVES: The purpose of this review is to provide an overview of what is currently known about the adverse events of long-term use of opioids in CNCP. It also delivers patient-centered strategies designed to mitigate these risks. METHODS: We conducted a literature search in PubMed, MEDLINE, EMBASE, and Web of Science databases. Search terms included CNCP, pain pathophysiology, opioid pharmacodynamics, opioid prescribing trends, guidelines for opioid use, and opioid side effects.  Results: Our review highlights that while opioids may provide short-term relief from CNCP, their effectiveness diminishes over time due to the development of opioid tolerance. This tolerance often leads to increased dosages, which can subsequently result in opioid dependence. Additionally, long-term opioid therapy is associated with a spectrum of adverse effects, including constipation, drowsiness, respiratory depression, and potential for drug interactions. Furthermore, our review indicates that alternative pain management strategies play a crucial role in controlling CNCP. They offer significant benefits with fewer adverse events. These strategies include non-opioid medications, physical therapy, cognitive-behavioral therapy (CBT), various interventional procedures, injection therapy, and acupuncture. CONCLUSION: Using opioids to manage CNCP presents several challenges. Given these challenges, alternative treatments are being considered as viable options. Moreover, it is crucial to customize treatment plans to align with the patients' specific health requirements, existing conditions, and potential risks to ensure the best possible outcomes.

Measurement of Condylar Offset and Posterior Condylar Cartilage Thickness in Normal Knees: An MRI Study From Saudi Arabia.

Background The maximum amount of knee flexion after total knee replacement is largely determined by the knee's posterior condylar offset (PCO). Using magnetic resonance imaging (MRI), this study examined the relationship between PCO and the thickness of the femoral posterior condylar cartilage (PCC) in healthy people. Methodology We reviewed the medical records of 300 skeletally mature patients who did not exhibit symptoms of knee arthritis and had undergone MRI for traumatic soft tissue knee injuries that did not affect the femoral PCC. Results The study cohort consisted of 300 participants, of whom 68.3% (205) were male, and 31.7% (95) were female aged between 18 and 59 years, with a mean age of 31.13 ± 8.83 years. Most participants were under 30 years of age (45.7%), and the mean body mass index was 27.52 ± 5.64 kg/m2. The total medial distance was 28.50 ± 3.11 mm, ranging from 21.20 to 39.80 mm. The medial PCC was 1.71 ± 0.63 mm, ranging from 0.60 to 4.00 mm. The medial bony PCO was 38.40 mm, ranging from 18.80 to 38.40 mm. The total lateral distance was 25.24 ± 3.16 mm, ranging from 13.50 to 34.90 mm. The lateral PCC was 1.48 ± 0.75 mm, ranging from 0.30 to 10.70 mm. Finally, the lateral bony PCO was 23.76 ± 3.19 mm, ranging from 11.99 to 32.8 mm. There was a statistically significant weak positive relationship between the bony lateral PCO and the patients' age in females only (p = 0.016; r = 0.00-0.39). There was a statistically significant mean difference in the total medial distance, medial PCC, and lateral PCC between the two knees (p < 0.05). Conclusions These findings shed light on the factors influencing these parameters, offer insightful information about the associations between particular patient characteristics and knee measurements, and may help guide clinical evaluations and treatment decisions.

Retraction: Giant Unruptured Internal Carotid Artery Aneurysm.

[This retracts the article DOI: 10.7759/cureus.20423.].

Pericardial hydatid cyst: The water lily sign as a classical sign in a nonclassical location.

Hydatid disease is a parasitic infection that usually targets the liver and is rarely seen affecting the heart. Herein, we present an incidentally diagnosed cardiac hydatid cyst with a pathognomonic radiological feature of a water lily sign.

Adhesive capsulitis following COVID-19 vaccination: a case report and review of literature.

Shoulder injury related to vaccine administration (SIRVA) has been frequently reported adverse event following COVID-19 vaccination. Multiple studies have reported various injuries including subacromial bursitis, rotator cuff tears, nerve injury, and most commonly, adhesive capsulitis. Adhesive capsulitis is defined as an inflammatory disease of the joint capsule characterized by pain and stiffness. Herein, we present a case of a 38-year-old female, known to have uncontrolled diabetes mellites and asthma, presented to upper extremity orthopedic clinic complaining of 6 months history of left shoulder pain and limited range of motion following COVID-19 vaccination administration. Clinical examination and radiological studies were consistent with adhesive capsulitis, the patient was then referred for intensive rehabilitation program that provided adequate response. In conclusion, the main etiology of SIRVA has been attributed to suboptimal injection technique, a standardized definition, implementation of safe vaccines injection protocols, and further education and awareness of SIRVA is needed to healthcare practitioners to allow better understanding and prevention.

Lateral epicondyle to the joint line distance is a precise landmark for determination of an accurate knee joint line: an observational retrospective study.

PURPOSE: To assess a quantitative and reproducible association between the position of the knee joint line and recognizable anatomical landmarks around it in order to help in restoring joint line in arthroplasty cases. METHODS: Magnetic resonance imaging (MRI) of 130 normal knees were investigated. Anatomical measurements of the knee joint distances on the obtained planes were performed manually by distance measurements using a ruler tool, followed by 6 anatomical bony landmarks determination about the knee to identify the joint line which included the joint line, medial epicondyle, lateral epicondyle, medial flare, lateral flare, and proximal tibiofibular joint. The entire process was examined twice by two independent fellowship trained musculoskeletal radiologists, with a 2-week interval between the first and second sets of readings. RESULTS: The lateral epicondyle to the joint line of the knee (LEJL) could be a reliable landmark for accurate distance measurements for the knee joint line level, with an absolute distance of 24.4 ± 2.8 mm. The analysis showed that the femorotibial ratio between the LEJL and proximal tibiofibular joint (PTFJ) was 1.0 (LEJL/PTFJJL = 1.0 ± 0.1), confirming the location of the knee joint at the midpoint between the lateral epicondyle and PTFJ, revealing two identifiable landmarks. CONCLUSIONS: LEJL is the most precise landmark for determination of an accurate knee joint line because the knee is located at the midline between the lateral epicondyle and PTFJ. These reproducible quantitative relationships can be widely employed in various imaging modalities to help restore the knee JL in arthroplasty surgeries.

Radiological outcome of bone disease in multiple myeloma patients pre- and post therapy: A single center experience.

OBJECTIVES: To find any correlation between the clinical response as per International Working Myeloma Group (IWMG) response criteria and the radiological response at the end of treatment. METHODS: A retrospective cohort study was conducted, total of 39 patients whom diagnosed with multiple myeloma (MM) between January 2010 and December 2018 and fulfilled the study criteria were included. RESULTS: The high sensitivity and specificity of positron emission tomography/computed tomography (PET/CT) in detecting osteolytic myeloma lesions in the bones was strongly emphasized in our study. Follow up PET/CT, we found that while 17 patients showed complete remission in PET/CT, and 14 of these of patients demonstrated a complete clinical response at end of therapy assessment. CONCLUSION: Although we did not find a statistically significant correlation between the response versus metabolic activity and the number of bone/bone marrow lesions, however, our study was limited by the absence of clear criteria for defining disease response in PET/CT in MM patients. Further prospective analysis would be needed to establish a defined criterion.

Clinical and Radiological Outcomes Following Medial Pivot Total Knee Arthroplasty: A Retrospective Chart Review Study.

Medial pivot total knee arthroplasty (MP-TKA) is a relatively new design that simulates normal knee mechanics with the aim of enhancing postoperative recovery. Furthermore, it reduces postoperative complications in patients with end-stage osteoarthritis of the knee. No study has been done regarding this topic in Saudi Arabia yet, so we aimed to study the post-operative clinical and radiological outcomes of MP-TKA, as well as the postoperative complications. A retrospective cohort chart review study was conducted on 46 patients and 70 knees after applying our inclusion/exclusion criteria. The patients were followed up for an average period of two years. Clinical outcomes were assessed pre- and postoperatively by the validated Saudi Arabian version of the Knee Injury and Osteoarthritis Outcome Score (KOOS), as well as radiological outcomes and postoperative complications gathered from patients' charts. The postoperative KOOS score showed a statistically significant improvement in pain, symptoms, and activities of daily living in comparison with the preoperative score (P-value < 0.0001). The mean time until ambulation and length of hospital stay were five and 14 days, respectively. Four patients (8.7%) showed radiological complications. Deep vein thrombosis was observed in only two knees (4.3%), and there were no revision cases. Thus, MP-TKA has been shown to improve pain, symptoms, and activities of daily living with a relatively short time until ambulation and length of hospital stay, in addition to a low incidence of postoperative and radiological complications.

The effect of gender, age, and body mass index on the medial and lateral posterior tibial slopes: a magnetic resonance imaging study.

BACKGROUND: The posterior tibial slope (PTS) is crucial in knee joint stability and in maintaining the natural movement of the knee. An increase in the PTS is associated with various knee pathologic conditions, such as anterior cruciate ligament (ACL) injury and anterior tibial translation (ATT). In the present study, we aimed to establish native medial and lateral PTS values for adult Saudis and to identify any association between PTS and gender, age, and body mass index (BMI). MATERIALS AND METHODS: A total of 285 consecutive, normal, magnetic resonance imaging (MRI) studies of the knee were included in the study. The PTS was measured using the proximal anatomical axis of the tibia. The Kruskal-Wallis test was used to compare the medial and lateral PTS angles between age groups. The difference between the medial and lateral posterior tibial slopes was assessed using the Wilcoxon signed-rank test. The Mann-Whitney U test was performed to compare the medial and lateral PTS angles between men and women. Age, gender, and BMI were analyzed by multivariate linear regression to determine whether they positively predict the medial and lateral PTS angles. RESULTS: The mean physiological medial PTS was 5.86 ± 3.0° and 6.61 ± 3.32°, and the lateral PTS was 4.41 ± 3.35° and 4.63 ± 2.85° in men and women, respectively. This difference showed no statistically significant gender dimorphism (p > 0.05). The medial PTS was significantly larger than the lateral PTS (p < 0.0001). There was no statistically significant difference in the medial and lateral PTS angles between age groups (p > 0.05). Higher BMI was significantly associated with a steeper medial PTS (p = 0.001). CONCLUSIONS: This study provided native values for medial and lateral PTS angles in Saudis, which can assist surgeons in maintaining normal knee PTS during surgery. The PTS was not influenced by age. The medial PTS was significantly larger than the lateral PTS in men and women. The PTS showed no significant gender dimorphism. BMI was significantly associated with the medial PTS.

Temporomandibular joint involvement in children with juvenile idiopathic arthritis: A single tertiary-center experience.

OBJECTIVES: To describe the clinical and laboratory characteristic, state the treatment and outcome of patients with juvenile idiopathic arthritis (JIA), and describe temporomandibular joint (TMJ) involvement as observed in a large tertiary center. METHODS: A retrospective cross-sectional study of children diagnosed with JIA was assessed at King Abdullah Specialist Children's Hospital, Riyadh, Saudi Arabia (2015-2019), which included a descriptive analysis of children who had TMJ involvement among our study group. Subjects diagnosed with the TMJ arthritis were based either on clinical musculoskeletal examination or using contrast-enhanced MRI. RESULTS: We reviewed 123 cases with different JIA subtypes (57% females). The most frequent subtype is the oligoarticular (36%). TMJ involvement was found in 16% (n=20/123) of the patients, of whom 45% had Polyarticular JIA. The rheumatoid factor was positive in 25%; antinuclear antibody (ANA) in 45% and none showed positivity to HLAB27. Treatment resulted in complete resolution in 95% of cases, while Micrognathia and obstructive sleep apnea were the complications reported in 5% of cases. CONCLUSION: TMJ involvement in JIA is not uncommon. Females with polyarticular disease were more frequently affected with TMJ arthritis. Positive ANA could be a risk factor for TMJ involvement, while positive HLAB27 might have some protective effects. Early treatment for TMJ arthritis is essential to avoid possible complications.

Giant Unruptured Internal Carotid Artery Aneurysm.

Headache is among the most frequent symptoms to seek medical care. Careful evaluation by history-taking and appropriate physical examination is needed to exclude the potential secondary causes of headaches. In the elderly population, secondary headaches are more prevalent compared with the younger adult population. We present the case of a 70-year-old man who presented with a three-month history of headache with visual disturbances. He reported that this was the first time he experienced such a headache. The patient had a longstanding history of hypertension, diabetes mellitus, dyslipidemia, and ischemic heart disease. He was a heavy smoker with a 35 pack-years smoking history. In view of the clinical signs and symptoms, the patient underwent a computed tomography scan that revealed a right internal carotid artery aneurysm. For better evaluation, magnetic resonance imaging of the brain was performed and re-demonstrated the saccular aneurysm of the terminal part of the right internal carotid artery aneurysm, measuring 48 x 37 x 31 mm and partially thrombosed with a surrounding mural hematoma. The neck of the aneurysm measured 4 mm. The decision for surgical management was planned. The patient underwent craniotomy with surgical clipping of the aneurysm. No complications occurred during the operation. The patient had an uneventful recovery. Elderly patients with chronic headaches should be carefully evaluated for secondary headaches. A giant cerebral artery aneurysm is an uncommon etiology of secondary headache that needs prompt diagnosis and management.

Variability of the Posterior Tibial Slope in Saudis: A Radiographic Study.

Aim The present study aimed to establish the normal range of the posterior tibial slope (PTS) angle in the Saudi adult population and to identify whether there was an association between the angle and gender or age. Materials and methods A total of 524 normal knee radiographs of 410 patients aged 18-85 years were included in the study. The PTS was measured using the anterior tibial cortex method. Data were matched with gender and age for statistical analysis. Results  The mean physiological PTS angle was 13.6 ± 3.4˚ (range: 3.8-23.9˚). Age and gender did not influence the PTS value (P >0.05). The two-way analysis of variance (ANOVA) test showed no interaction effect between age and gender on the PTS (P >0.05). Conclusions This study provided a reference range for the normal PTS among Saudis, which can assist in decision-making during different knee procedures. The PTS value did not significantly differ between male and female subjects, and there was no significant association between the PTS angle and age.

Spinal Pseudoaneurysms Mimicking an Osteogenic Tumor: A Case Report.

AIM: This study presents a rare case of pseudoaneurysm mimicking a tumor on the back, with no history of fever, trauma, or surgical intervention. In which no identifiable symptoms or warning signs were present. This pseudoaneurysm arises from intercostal arteries and segmental arteries. Both of which, to the limit of our knowledge, have not been discussed before. METHOD: This study was done using chart and literature review. We present a case of a 46-year-old man with a known case of left-sided intracranial hemorrhage due to hypertension and an old cerebrovascular accident. The patient has a positive history of hypertension, which could have attributed to the pseudoaneurysm; however, he has no history of vascular disease otherwise. The patient reports of back swelling and intermittent back pain for the past 3 years. On MRI, the mass showed a pulsating pattern around it. It also showed a layering effect because of different wall thicknesses and enhanced patterns, and the enhancement ratio was increased. In addition, it showed flow artifacts with T1 hyperintense areas because of associated thrombus and blood products. These changes noted on the MRI prompted the team to do a color Doppler study to confirm the presence of an aneurysm and if present, to do a CT angiography. The color Doppler showed a turbulent flow, that is, there was a bidirectional pulsatile flow which further confirms the presence of a pseudoaneurysm. Spine CT with contrast showed a right paraspinal lesion at the T9-T11 level. It had contrast enhancement and flow inside, consistent with a partially thrombosed aneurysm. The CT also showed evidence of bone remodeling in the adjacent thoracic vertebrae. The patient opted for spinal vascular emobilization and vascular sheath removal. The right and left intercostal arteries were selected at the level of left and right T4, left T8, bilateral T9, and bilateral T10. CONCLUSION: Differentiating between pseudoaneurysms and osteogenic tumors is essential to target later investigations accordingly. In addition, if pseudoaneurysms are left untreated, they could cause bony erosions of the vertebra, which lead to compression fractures. They can further compress the adjacent neurovasculature, which worsens the morbidity.

Unusual Presentation of Fibrous Dysplasia in an Elderly Patient.

Fibrous Dysplasia is a benign fibro-osseous lesion occurring throughout the skeletal system with a predilection for craniofacial bones, long bones, and ribs. Fibrous dysplasia develops during bone formation and growth with a variable natural evolution. It is considered a genetic nonheritable disease resulting from missense mutations that occur postzygotically in the GNAS1 gene. This mutation leads to a focal congenital failure of proper bone formation and arrest at the woven bone stage. In turn, this leads to a decreased mechanical strength, causing bone pain, pathological fractures, and skeletal deformities. Besides clinical examination, fibrous dysplasia is diagnosed based on the results of radiographic imaging and the microscopic histopathological findings. On CT scan, fibrous dysplasia shows the characteristic "Ground-glass" appearance with well-defined borders. On MRI, fibrous dysplasia has a low signal intensity on T1-weighted MRI and variable signal intensity on T2-weighted MRI. We hereby report a case of an unusual presentation of fibrous dysplasia in a 67-year-old female presenting to the emergency department with generalized malaise and lower limb pain. Fibrous dysplasia may present in the elderly population and can be difficult to differentiate from other malignant and benign lesions affecting the skeletal system.

Neurological disability among adults following traumatic spinal fractures in Saudi Arabia: a retrospective single-center medical record review.

BACKGROUND: A traumatic spinal fracture (TSF) is a serious condition that has a tremendous impact on patients and their families. Understanding the causes and patterns of TSF is critical in developing prevention programs. OBJECTIVES: Identify causes and patterns of TSF and explore predictors of neurological disability in Saudi Arabia. DESIGN: A retrospective medical record review. SETTING: Level 1 trauma center in Riyadh. PATIENTS AND METHODS: The analysis included all consecutive patients who met the inclusion criteria for any acute TSF in patients 18 years of age and older from January 2001 to January 2016. A multivariate logistic regression model was used to identify predictors of neurological disability following TSF. MAIN OUTCOME MEASURES: Neurological disability in patients sustaining TSF. SAMPLE SIZE: 1128 patients. RESULTS: Of 1128 patients, 971 patients (86%) were male with a mean (SD) age 34.4 (16.6) years. The most common mechanism of injury was motor vehicle accidents (88.4%). Cervical spine was the most commonly affected region (48%, n=468) with a mortality rate of 7.6%. Neurological disability occurred in 74 (6.7%) patients, and 41 (8.7%) of those with cervical fractures died in the hospital. The Injury Severity Score was a significant predictor of neurological disability following TSF. CONCLUSION: A high proportion of neurological disability following TSF was found. Further studies should attempt to improve the docu.mentation rate of seatbelt status in all traumatic cases including mild injuries. This data will increase our understanding of adult TSF and possibly facilitate injury prevention strategies. LIMITATIONS: Single hospital and may not be generalizable. CONFLICT OF INTEREST: None.