Development of a Cadaver Laboratory Curriculum for Interventional Spine Procedures for Physical Medicine and Rehabilitation Residents.

ABSTRACT: There is no standardized curriculum for teaching interventional spine procedures during residency. The objective of this protocol was to share a curriculum using a cadaver laboratory for teaching Physical Medicine and Rehabilitation residents interventional spine procedures, which can be an effective and safe medium to train residents. This protocol provides a checklist that can guide the residents while they are in the cadaver laboratory with a focus on some of the most common lumbar procedures. Twelve physical medicine and rehabilitation resident's confidence in their ability to maneuver the x-ray image intensifier (C-arm), identify spine anatomy under fluoroscopy, and drive the needle improved after the training curriculum (P < 0.005). Although the cadaver laboratory curriculum is not a replacement for the required Accreditation Council for Graduate Medical Education training, it may serve as a tool to improve resident preparedness for spine procedures.

Cervical medial branch block progression to radiofrequency neurotomy: A retrospective clinical audit.

BACKGROUND: Chronic axial neck pain (CANP) due to zygapophysial joint arthropathy is best diagnosed via cervical medial branch block (MBB). However, the paradigm by which MBB is used to select patients for cervical radiofrequency neurotomy (RFN) is contested. Dual diagnostic cervical MBB with a minimum of ≥80% pain relief to diagnose cervical zygapophysial joint pain has been accepted by some Medicare Local Coverage Determinations as the method for selecting patients for cervical RFN. There are some who would argue that the utility of the dual diagnostic MBB and the ≥80% pain relief cut off lacks utility in clinical practice. The suspicion being those who progress from MBB1 to MBB2 will then flow from MBB2 to RFN without fail. Does clinical practice using dual diagnostic MBBs and using an ≥80% pain relief cut off reduce patient eligibility for cervical RFN after both MBB1 and MBB2? METHODS: A retrospective clinical audit was carried out at an academic institution spine center from January 1st to December 31st, 2019. Charts were selected based on Current Procedural Terminology codes for MBB, then included if the cervical medial branches were targeted. Charts were then reviewed for procedural progression. RESULTS: 21/51 (24%, 95% Confidence Interval 12-35%) patients progressed from MBB1 to MBB2. Of those 21 patients, 13 patients progressed from MBB2 to RFN (62%, 95% CI 41-83%). In total, 13/51 (14%, 95% CI 14-37%) patients who were initially suspected to have CANP due to zygapophysial joint pain progressed to RFN. Both MBB1 and MBB2 hindered the progression of 30/51 patients (59%, 95% CI 45-72%) and 8/21 patients (38%, 95% CI 17-59%), respectively. CONCLUSION: Both MBB1 and MBB2 served to filter patients from progression to RFN using dual MBBs with an ≥80% pain relief cutoff.

The Importance of Personally Reviewing Imaging for Clinical Correlation: A Case of Thoracic Spinal Stenosis Masquerading as a Motor Neuron Disease.

ABSTRACT: A 64-yr-old man with a history of previous motor vehicle collision with chronic back pain presented as a referral to an outpatient spine clinic with a 3-yr history of bilateral lower limb weakness and numbness that progressed to severe bilateral foot drop. He had been seen by another practitioner from a different hospital 2 yrs prior who performed an electromyography that was interpreted as possible primary lateral sclerosis. His clinical picture was difficult to interpret as it did not fit any of the disease patterns, such as a motor neuron disease, suggested by previous electromyography. Repeated magnetic resonance imaging revealed multifactorial canal stenosis at L3-L4 and L4-L5 with foraminal stenosis. The ordering physician reviewed the magnetic resonance imaging of lumbar spine and noticed possible spinal canal stenosis in the lower thoracic region, not noted by the radiologist, and ordered a magnetic resonance imaging of thoracic spine for further evaluation. Overall, this is an interesting case of a patient who had prolonged weakness and numbness in his lower limbs that, although he underwent extensive workup, was misdiagnosed. It is important to realize that thoracolumbar disc herniations can cause mixed upper motor neuron and lower motor neuron signs. This case emphasizes the importance of reviewing the patient's imaging personally and correlating the imaging to the clinic presentation.