Dorsal Root Ganglion Stimulation for the Management of Phantom Bladder Pain: A Case Report.

Phantom bladder pain, a rare condition following cystectomy, can pose a challenge to pain management providers. We present the case of a 43-year-old male who developed severe phantom bladder pain post-cystectomy. Despite multiple treatments, his symptoms persisted, significantly affecting his quality of life. Dorsal root ganglion stimulation (DRGS) was attempted after conventional therapies failed. The DRGS trial provided significant relief, leading to permanent implantation and a 90% reduction in pain. This case highlights DRGS as a potential treatment for phantom bladder pain, expanding its applications beyond traditional uses. Further research is needed to elucidate its mechanisms and broader applicability.

Restoration of sensory feedback from the foot and reduction of phantom limb pain via closed-loop spinal cord stimulation.

Restoring somatosensory feedback in individuals with lower-limb amputations would reduce the risk of falls and alleviate phantom limb pain. Here we show, in three individuals with transtibial amputation (one traumatic and two owing to diabetic peripheral neuropathy), that sensations from the missing foot, with control over their location and intensity, can be evoked via lateral lumbosacral spinal cord stimulation with commercially available electrodes and by modulating the intensity of stimulation in real time on the basis of signals from a wireless pressure-sensitive shoe insole. The restored somatosensation via closed-loop stimulation improved balance control (with a 19-point improvement in the composite score of the Sensory Organization Test in one individual) and gait stability (with a 5-point improvement in the Functional Gait Assessment in one individual). And over the implantation period of the stimulation leads, the three individuals experienced a clinically meaningful decrease in phantom limb pain (with an average reduction of nearly 70% on a visual analogue scale). Our findings support the further clinical assessment of lower-limb neuroprostheses providing somatosensory feedback.

Superior Cluneal Neuralgia Treated With Wireless Peripheral Nerve Stimulation.

Superior cluneal neuralgia (SCN) can often be misdiagnosed when evaluating a patient with low back pain (LBP). The pathomechanics of SCN can range from direct injury following surgeries or trauma to myofascial compression due to abnormal muscle tone or fibrosis. The authors present a case of SCN in a 65-year-old male that persisted for three years following a laminectomy complicated by retained hardware and subsequent fibrosis. The patient's diagnosis was confirmed with a diagnostic nerve block with significant pain relief after initial misdiagnosis and unsuccessful interventions targeting other possible pain generators. He ultimately underwent a successful peripheral nerve stimulation (PNS) trial and implantation with significant long-term pain relief. This case report entails the need to consider SCN in the differential for low back pain and the successful utilization of PNS for treatment.

Ureterocele as a cause of chronic intractable abdominal pain.

A ureterocele is a submucosal, cystic dilation of the terminal ureter, either congenital or acquired, as it enters the bladder. It is a rare clinical entity that can be entirely asymptomatic and present as an incidental finding or can manifest in the form of distressing symptoms such as unremitting abdominal pain, haematuria, obstructive uropathy, to name a few. The authors present a case of abdominal pain in a 43-year-old woman who was presumptively attributed to various clinical entities and was finally referred to the chronic pain clinic. The patient underwent numerous diagnostic tests, psychological evaluations and therapeutic interventions, including surgeries, over the years that failed to mitigate her symptoms until urologic imaging reported intravesical ureterocele as the underlying disorder. The case report entails the diagnostic challenge faced by the authors along with the clinical characteristics of ureterocele.

Bilateral symmetry in ankle-muscle activation in transtibial amputees.

By 2020, over 2.2 million people in the United States will be living with an amputated lower limb. The functional impact of amputations presents significant challenges in daily living activities. While significant work has been done to develop smart prosthetics, for the long-term development of effective and robust myoelectric control systems for transtibial amputees, there is still much that needs to be understood regarding how extrinsic muscles of the lower limb are utilized post-amputation. In this study, we examined muscle activity between the intact and residual limbs of three transtibial amputees with the aim of identifying differences in voluntary recruitment patterns during a bilateral motor task. We report that while there is variability across subjects, there are consistencies in the muscle recruitment patterns for the same functional movement between the intact and the residual limb within each subject. These results provide insights for how symmetric activation in residual muscles can be characterized and used to develop myoelectric control strategies for prosthetic devices in transtibial amputees.

Betadine-Soaked Alcohol Pad and Rigid Immobilization: An Inexpensive and Effective Method to Diminish Infections With Exposed Kirschner Wires in Hand Fractures.

This study describes a novel method of pin care with a Betadine-soaked alcohol pad in conjunction with immobilization to reduce pin site complications in hand fractures treated with exposed Kirschner wires (K-wires). We conducted a retrospective review of all phalangeal and metacarpal fractures from 2010 to 2016 treated with K-wire fixation, a Betadine-soaked alcohol pad, and immobilization in a well-moulded plaster cast. A total of 155 patients with metacarpal or phalangeal fractures were identified, of which 149 were included with 164 fractures treated with 217 exposed K-wires. Overall complication rate was 6.1% (10/164), of which 3 fractures (1.8%) developed infections. Two infections occurred in patients with a history of organ transplantation. The most common complication was stiffness requiring closed manipulation under anesthesia (2.4%, 4/164), resulting in full range of motion in 3 of 4 patients. Exposed K-wires remain an effective method of hand fracture fixation associated with a low complication rate.

La présente étude décrit une nouvelle méthode de soins des broches avec un tampon d'alcool imprégné de bétadine conjointement avec l'immobilisation pour réduire les complications au foyer des broches en cas de fractures de la main traitées par des broches K exposées. Les chercheurs ont effectué une analyse rétrospective de toutes les fractures phalangiennes et métacarpiennes traitées par des broches K entre 2010 et 2016, un tampon d'alcool imprégné de bétadine et une immobilisation dans un plâtre bien moulé. Ils ont repéré 155 patients victimes de fractures métacarpiennes ou phalangiennes et en ont inclus 149 qui ont été traités par 217 broches K exposées. Le taux de complication globale s'élevait à 6,1 % (dix sur 164) et trois fractures (1,8 %) se sont infectées. Deux infections se sont produites chez des patients ayant subi une transplantation d'organe. La complication la plus courante était une rigidité exigeant une manipulation fermée sous anesthésie (2,4 %, quatre sur 164), qui a favorisé une pleine amplitude de mouvement chez trois des quatre patients. Les broches K exposées demeurent une méthode efficace de fixation des fractures de la main, associées à un faible taux de complication.

Exoskeletal-Assisted Walking During Acute Inpatient Rehabilitation Leads to Motor and Functional Improvement in Persons With Spinal Cord Injury: A Pilot Study.

OBJECTIVE: To explore the potential effects of incorporating exoskeletal-assisted walking (EAW) into spinal cord injury (SCI) acute inpatient rehabilitation (AIR) on facilitating functional and motor recovery when compared with standard of care AIR. DESIGN: A quasi-experimental design with a prospective intervention group (AIR with EAW) and a retrospective control group (AIR only). SETTING: SCI AIR facility. PARTICIPANTS: Ten acute inpatient participants with SCI who were eligible for locomotor training were recruited in the intervention group. Twenty inpatients with SCI were identified as matched controls by reviewing an AIR database, Uniform Data System for Medical Rehabilitation, by an individual blinded to the study. Both groups (N=30) were matched based on etiology, paraplegia/tetraplegia, completeness of injury, age, and sex. INTERVENTION: EAW incorporated into SCI AIR. MAIN OUTCOME MEASURES: FIM score, International Standards for Neurological Classification of Spinal Cord Injury Upper Extremity Motor Score and Lower Extremity Motor Scores (LEMS), and EAW session results, including adverse events, walking time, and steps. RESULTS: Changes from admission to discharge LEMS and FIM scores were significantly greater in the intervention group (LEMS change: 14.3±10.1; FIM change: 37.8±10.8) compared with the control group (LEMS change: 4.6±6.1; FIM change: 26.5±14.3; Mann-Whitney U tests: LEMS, P<.01 and FIM, P<.05). One adverse event (minor skin abrasion) occurred during 42 walking sessions. Participants on average achieved 31.5 minutes of up time and 18.2 minutes of walk time with 456 steps in one EAW session. CONCLUSIONS: Incorporation of EAW into standard of care AIR is possible. AIR with incorporated EAW has the potential to facilitate functional and motor recovery compared with AIR without EAW.

Treatment of at-level spinal cord injury pain with botulinum toxin A.

Study design: Randomized, double-blinded, placebo-controlled, cross-over study. Objective: To explore whether botulinum toxin A (BoNTA) could be effective for treating at-level spinal cord injury (SCI) pain. Setting: Outpatient SCI clinic, New York, USA. Methods: Participants were randomized to receive subcutaneous injections of either placebo or BoNTA with follow-up (office visit, telephone, or e-mail) at 2, 4, 8, and 12 weeks to assess the magnitude of pain relief post injection. Crossover of participants was then performed. Those who received placebo received BoNTA, and vice versa, with follow-up at 2, 4, 8, and 12 weeks. Results: Eight participants completed at least one of the two crossover study arms. Four completed both arms. The median age of the eight participants was 45 years (range 32-61 years) and 75% were male. All had traumatic, T1-L3 level, complete SCI. Although our data did not meet statistical significance, we noted a higher proportion of participants reporting a marked change in average pain intensity from baseline to 8 and 12 weeks post-BoNTA vs. post-placebo (33% vs. 0%). At 2 and 4 weeks post-BoNTA, almost all participants reported some degree of reduced pain, while the same was not seen post-placebo (83% vs. 0%). Conclusion: The subcutaneous injection of BoNTA may be a feasible approach for the control of at-level SCI pain and is worthy of further study. Sponsorship: The onabotulinumtoxinA (BOTOX) used in this study was provided by Allergan (Irvine, CA).

Outcomes of displaced olecranon fractures treated with the Olecranon Sled.

BACKGROUND: Tension-band wiring is largely considered the gold standard for fixation of displaced olecranon fractures despite high rates of hardware complications. The purpose of this study was to report the outcomes of displaced olecranon fractures treated with the Olecranon Sled. METHODS: We retrospectively reviewed all displaced olecranon fractures from 2011-2015 treated with the Olecranon Sled. Inclusion was limited to functionally independent patients with Mayo type II fractures and minimum 12-month follow-up. We assessed clinical outcomes including range of motion; Disabilities of the Arm, Shoulder and Hand score; and Mayo Elbow Performance Score. RESULTS: Twenty-two patients with a mean follow-up period of 31.8 months (range, 12-71 months) were included in the study. All patients indicated satisfactory outcomes. The mean Mayo Elbow Performance Score was 95.5 (range, 70-100), and the mean Disabilities of the Arm, Shoulder and Hand score was 3.1 (range, 0-18.3). The mean total arc of elbow flexion was 145° (range, 134°-158°), and the mean total arc of forearm rotation was 175° (range, 160°-180°). There were no hardware-related complications. The overall complication rate was 4.5% (1 of 22) as significant heterotopic ossification developed in 1 patient, requiring contracture release. CONCLUSION: The Olecranon Sled is a reliable and well-tolerated implant for the treatment of olecranon fractures. This device results in excellent functional outcomes and may obviate hardware removal.

Arthroscopic versus open excision of dorsal ganglion cysts: a systematic review.

We conducted a systematic review comparing recurrence and complication rate following open versus arthroscopic excision of ganglion cysts. Sixteen full-text articles were included. The pooled recurrence rate of open excision was 20% (range: 5.6-40.7%) with Q value of 27 and I2 of 82%. The pooled recurrence rate of arthroscopic excision was 9% (range: 0-17%) with Q value of 10 and I2 of 2%. Eleven of 16 studies were low quality or had a high risk of bias; however, excluding low quality studies or those with high risk of bias produced similar recurrence rates in arthroscopic and open excision (7.9% versus 9.8%). For the subset of studies with complete reporting of complications, rates were similar in open and arthroscopic excision (6% versus 4%). Our review suggests that arthroscopic and open approaches have comparable outcome profiles. Nevertheless, standardized study methods with adequate powering are required to collect high quality data, allowing for greater confidence in conclusions regarding these two approaches for existing ganglion cysts. LEVEL OF EVIDENCE: II.

Modified frailty index associated with Clavien-Dindo IV complications in robot-assisted radical prostatectomies: A retrospective study.

OBJECTIVE: To determine the effect of frailty on patient outcomes including any complication, Clavien-Dindo IV (CDIV) (intensive care unit-level) complications, and 30-day mortality for robotic-assisted radical prostatectomies (RARP) patients in comparison to other predictive indices using the modified frailty index (mFI). MATERIAL AND METHODS: Patients undergoing RARP from 2008 to 2014 for a prostate cancer-related diagnosis were queried using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database. The mFI was developed using the Canadian Study of Health and Aging Frailty Index as a model. The mFI was compared with other associative indices such as the American Society of Anesthesiology (ASA) classification and the Charlson comorbidity index (CCI). Rates of CDIV complications and 30-day mortality were analyzed based on mFI score using SAS version 9.22. RESULTS: A total of 23,104 patients undergoing RARP were queried. RARP patients with the highest frailty score (≥3) had an adjusted odds for CDIV complications of Odds ratio of 12.107 (CI: 2.800-52.351, P< 0.005) in comparison with nonfrail RARP patients. These odds were higher than the ASA and Charlson comorbidity index. Additionally, a variable combining mFI and ASA had fair sensitivity and specificity for predicting 30-day mortality in RARP patients (C-statistic = 0.7097, P<0.0001). CONCLUSION: Increasing mFI scores are associated with worsening outcomes for patients undergoing RARP. A combined mFI and ASA variable can be used to predict 30-day mortality for RARP patients better than mFI or ASA alone.