Clinical Significance of Maximum Intensity Projection Method for Diagnostic Imaging of Thoracic Outlet Syndrome.

The aim of this study was to use the magnetic resonance imaging maximum-intensity projection (MRI-MIP) method for diagnostic imaging of thoracic outlet syndrome (TOS) and to investigate the stricture ratios of the subclavian artery (SCA), subclavian vein (SCV), and brachial plexus bundle (BP). A total of 113 patients with clinically suspected TOS were evaluated. MRI was performed in a position similar to the Wright test. The stricture was classified into four grades. Then, the stricture ratios of the SCA, SCV, and BP in the sagittal view were calculated by dividing the minimum diameter by the maximum diameter of each structure. Patients were divided into two groups: surgical (n = 22) and conservative (n = 91). Statistical analysis was performed using the Mann-Whitney U test. The stricture level and ratio in the SCV were significantly higher in the surgical group, while the stricture level and the ratio of SCA to BP did not show significant differences between the two groups. The MRI-MIP method may be helpful for both subsidiary and severe diagnoses of TOS.

High-definition magnetic resonance images on medial elbow injuries in preadolescent Little Leaguers.

BACKGROUND: The incidence of throwing-related elbow injuries is still rising. The study aimed to enhance the pathology of acute medial elbow injuries among young Little Leaguers by examining the medial elbows of symptomatic 9-10 years old Little Leaguers using High-Definition Magnetic Resonance Images (HDMRI), which uses a small-diameter surface coil on the target area, leading to greater image resolution. METHOD: We identified Little Leaguers aged 9-10 years old. To minimize the detection of the chronic adaptative changes, players who experienced the medial elbow pain previously and whose HDMRI had not been taken within 4 weeks from the onset of medial elbow pain were excluded. This study considered 21 players, and the mean age was 9.4 ± 0.5 years. RESULT: The fragmentation of the medial epicondyle apophysis via HDMRI was found in 15 elbows (71.4%), while the avulsion was seen in three cases. The signal hyperintensity at the medial epicondyle apophysis was observed in 2 cases. Our data showed abnormal changes to the medial epicondyle apophysis and surrounding structures, such as the ulnar collateral ligament (UCL), flexor-pronator tendons or the coronoid process of the ulna. We detected 11 abnormalities on X-ray imaging, while 20 subjects showed some abnormal findings via HDMRI. DISCUSSION: The current study showed that initial medial elbow injury in Little Leaguers without a history of previous elbow injury could be attributed to multi-structure injury. Over 90% of subjects were injured in the perichondrium, while 71.4% demonstrated a fragmentation of the secondary ossification center, and 14.3% experienced an avulsion of the medial epicondyle apophysis. Because the injuries were not limited to bony structures, HDMRI may be beneficial for the appropriate evaluation of medial elbow pain. The pathology of initial medial elbow injuries in young baseball players may be due to acute trauma instead of repetitive microtrauma.

Biofeedback Physical Therapy With the Hybrid Assistive Limb (HAL) Lumbar Type for Chronic Low Back Pain: A Pilot Study.

Objective There are many treatments for chronic low back pain, including various medications, exercise therapy, orthotics, and surgery, but no treatment is definitive. We hypothesized that biofeedback therapy using the hybrid assistive limb (HAL) lumbar type would have some immediate effects on chronic low back pain. The purpose of this pilot study was to assess whether immediate changes in low back pain and hip flexibility and any other adverse events would occur following the HAL biofeedback physical therapy. Methods This was a single-center, pilot, prospective, single-arm study of outpatient biofeedback physical therapy using the HAL lumbar type for patients with chronic low back pain. Patients underwent a 10-minute biofeedback physical therapy (lumbar flexion-extension, sit-to-stand, and squat) with the HAL lumbar type (in one session). The visual analog scale (VAS) score of low back pain during lumbar flexion, extension, lateral bending, and rotation was evaluated. The finger-to-floor distance (FFD), straight leg raising test (SLR), and the Thomas test were measured to assess hip flexibility. Results All 35 participants (14 men and 21 women) (100%) conducted a biofeedback HAL therapy session using the HAL lumbar type. No participant had deterioration of low back pain. No adverse events occurred. After the biofeedback therapy using the HAL lumbar type, SLR demonstrated a significant positive change with large effect size and sufficient power. Lumbar VAS during lumbar flexion and extension and FFD showed a significant positive change with medium effect size and adequate power. Conclusions Biofeedback therapy using the HAL lumbar type is an option for intervention in chronic low back pain.

A Magnetic Resonance Imaging-Based Staging System for Osteochondritis Dissecans of the Elbow: A Validation Study Against the International Cartilage Repair Society Classification.

BACKGROUND: Evaluations of the stability of osteochondritis dissecans (OCD) lesions of the elbow using magnetic resonance imaging (MRI) have resulted in reports with variable accuracy. Therefore, the International Cartilage Repair Society (ICRS) classification remains the gold standard to determine OCD lesion stability. Because OCD commonly occurs in pediatric patients, a noninvasive method comparable with the ICRS classification is desired. HYPOTHESIS/PURPOSE: Based on the previous literature, the capitellum of unstable OCD lesions has an irregular outline on MRI because of displacement or dislocation of the lesion via synovial fluid inflow. Therefore, we defined a 4-stage classification, similar to the ICRS classification, which focused on the outline of the capitellum and articular cartilage status on MRI without subchondral bone information. The purpose of this study was to validate this MRI-based staging system against the ICRS classification and to verify its accuracy in diagnosing unstable OCD lesions of the elbow. STUDY DESIGN: Cohort study (diagnosis); Level of evidence, 2. METHODS: A total of 81 patients with OCD of the elbow who were surgically treated were evaluated. The MRI-based stages were as follows: stage 1, normal-shaped capitellum and articular cartilage without signal intensity change; stage 2, normal-shaped capitellum and articular cartilage with signal intensity change; stage 3, irregular-shaped capitellum and discontinuity of the articular cartilage; and stage 4, dislocated lesion with an articular cartilage defect. Agreement between the MRI and ICRS classifications was evaluated, and the sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) for lesion instability were determined. The intraclass correlation coefficient (ICC) for intrarater and interrater reliability of the MRI-based staging system was calculated. RESULTS: Agreement between the MRI-based staging system and the ICRS classification was 88.9%, with a sensitivity of 98.4%, specificity of 84.2%, PPV of 95.3%, and NPV of 94.1% for diagnosing an unstable lesion. The ICC was high for both intrarater (0.925) and interrater (0.915-0.939) reliability. CONCLUSION: The MRI-based staging system corresponded well with the ICRS classification, providing an accurate preoperative assessment of OCD lesions of the elbow, even with minimal subchondral bone information.

Effects of postoperative administration of celecoxib on pain management in patients after total knee arthroplasty: study protocol for an open-label randomized controlled trial.

BACKGROUND: Multimodal analgesia is achieved by combining different analgesics and different methods of analgesic administration, synergistically providing superior pain relief when compared with conventional analgesia. Multimodal analgesia can also result in reductions in the side effects and complications of analgesia, thereby improving patient safety. Preventive analgesia, treatment before initiation of the surgical procedure, has a potential to be more effective in reducing pain sensitization than treatment initiated after surgery. Multimodal analgesia that includes prophylactic administration of selective cyclooxygenase-2 (COX-2) inhibitors can improve postoperative pain and reduce opioid analgesic consumption after total knee arthroplasty (TKA). However COX-2 inhibitors are not approved for use as preventive analgesia in Japan. Thus, assessing the effectiveness of COX-2 inhibitors during the early postoperative period is important to establish clinical practice guidelines in Japan. This study was designed to examine the effects of celecoxib administration immediately after surgery, in addition to multimodal analgesia, on postoperative pain management after TKA. METHODS/DESIGN: This randomized, prospective, open-label controlled study will include 120 patients undergoing unilateral TKA. All patients will routinely receive single injections of femoral and sciatic nerve blocks, along with postoperative patient-controlled analgesia (PCA) with fentanyl. Patients will be randomly assigned to receive or not receive immediate postoperative administration of celecoxib. The primary outcome is a visual analog scale (VAS) pain score the second day after surgery. Secondary outcomes include opioid consumption, VAS pain score for 7 days after surgery, range of knee motion, evaluation of sleep quality, overall evaluations by patients and physicians, rates of postoperative nausea and vomiting, and consumption of rescue analgesics. DISCUSSION: The objective of this study is to evaluate the effects of celecoxib administration immediately after surgery on pain after TKA surgery. A randomized controlled trial design will address the hypothesis that administration of oral celecoxib immediately after surgery, along with multimodal analgesia that includes peripheral nerve block and PCA, could reduce VAS pain score after TKA surgery. TRIAL REGISTRATION: UMIN-CTR 000014624 (23 July 2014).

High-resolution axial MR imaging of tibial stress injuries.

PURPOSE: To evaluate the relative involvement of tibial stress injuries using high-resolution axial MR imaging and the correlation with MR and radiographic images. METHODS: A total of 33 patients with exercise-induced tibial pain were evaluated. All patients underwent radiograph and high-resolution axial MR imaging. Radiographs were taken at initial presentation and 4 weeks later. High-resolution MR axial images were obtained using a microscopy surface coil with 60 × 60 mm field of view on a 1.5T MR unit. All images were evaluated for abnormal signals of the periosteum, cortex and bone marrow. RESULTS: Nineteen patients showed no periosteal reaction at initial and follow-up radiographs. MR imaging showed abnormal signals in the periosteal tissue and partially abnormal signals in the bone marrow. In 7 patients, periosteal reaction was not seen at initial radiograph, but was detected at follow-up radiograph. MR imaging showed abnormal signals in the periosteal tissue and entire bone marrow. Abnormal signals in the cortex were found in 6 patients. The remaining 7 showed periosteal reactions at initial radiograph. MR imaging showed abnormal signals in the periosteal tissue in 6 patients. Abnormal signals were seen in the partial and entire bone marrow in 4 and 3 patients, respectively. CONCLUSIONS: Bone marrow abnormalities in high-resolution axial MR imaging were related to periosteal reactions at follow-up radiograph. Bone marrow abnormalities might predict later periosteal reactions, suggesting shin splints or stress fractures. High-resolution axial MR imaging is useful in early discrimination of tibial stress injuries.

Factors associated with lumbar intervertebral disc degeneration in the elderly.

BACKGROUND CONTEXT: Lumbar intervertebral disc degeneration (DD) precedes degenerative diseases of the lumbar spine. Various factors in addition to normal aging are reported to be associated with DD, and recently atherosclerosis and risk factors for cardiovascular diseases (cardiovascular risk factors) have received much attention; however, the links between these risk factors and DD are unclear. PURPOSE: By correlating magnetic resonance images (MRI) with suspected degenerative disc risk factors such as obesity, cardiovascular risk factors, and atherosclerosis, we hope to clarify the factors associated with DD. STUDY DESIGN/SETTING: An observational study. PATIENT SAMPLE: Two hundred seventy adults (51-86 years old) who participated in a health promotion program. OUTCOME MEASURES: DD evaluated based on the signal intensity of MR T2-weighted mid-sagittal images of the lumbar spine. METHODS: Age, gender, body mass index (BMI), low-density lipoprotein cholesterol (LDLc), triglyceride (TG), glycosylated hemoglobin (HbA(1c)), brachial-ankle pulse wave velocity (baPWV) as an index of atherosclerosis, osteo-sono-assessment index (OSI) calculated from quantitative ultrasound assessment of the calcaneus as an index of bone mineral density (BMD), history of low back pain (LBP), smoking and drinking habits, and physical loading related to occupations and sports were assessed. The univariate relationships between DD and the variables were evaluated, and finally, odds ratios (OR) and 95% confidence intervals (CI) for the associations of each factor with DD were calculated using logistic regression at each disc level. RESULTS: Aging correlated significantly with DD of L1/2 (OR, 2.14), L2/3 (OR, 3.56), L3/4 (OR, 2.84), and L4/5 (OR, 3.05); high BMI, with L2/3 (OR, 2.98), L3/4 (OR, 3.58), L4/5 (OR, 2.32), and L5/S1 (OR, 3.34); high LDLc, with L4/5 (OR, 2.65); occupational lifting, with L1/2 (OR, 4.25); and sports activities, with L5/S1 (OR, 3.36). CONCLUSIONS: Aging, high BMI, high LDLc, occupational lifting, and sports activities are associated with DD. The results of this study raise our index of suspicion that cardiovascular risk factors and particular physical loading may contribute to DD; however additional studies are required to further investigate associations between DD and these factors.

Lumbar intervertebral disk degeneration in elite competitive swimmers: a case control study.

BACKGROUND: The majority of orthopaedic problems experienced by competitive swimmers are related to pain in the shoulder, low back, and knee. Three of 39 national swim team members were hampered in their performance due to lumbar disk herniation at an international competition in 2001. There has been no previous research into lumbar disk degeneration in elite competitive swimmers. HYPOTHESIS: Excessive competitive swimming activities accelerate lumbar disk degeneration. STUDY DESIGN: Case control study; Level of evidence, 3. METHODS: Fifty-six elite swimmers (high-load group, 35 men and 21 women; mean age, 19.6 years) and a control group of 38 university recreational level swimmers (low-load group, 24 men and 14 women; mean age, 21.1 years) were evaluated for lumbar disk degeneration using magnetic resonance imaging. We compared the prevalence of disk degeneration and the disk level between the 2 groups and further investigated the relationship among their symptoms, swimming styles, and disk degeneration. RESULTS: Thirty-eight (68%) elite swimmers and 11 (29%) controls had degenerated disks at various disk levels, and the prevalence was significantly greater in the elite swimmers (P = .0002). Comparison between the 2 groups of the prevalence of disk degeneration at each level revealed that the disk level of L5-S1 was significantly more frequently degenerated in the high-load group (P = .026). There was no significant relationship observed among the variables of low back pain symptoms, swimming strokes, and disk degeneration. CONCLUSION: Excessive competitive swimming activities might exaggerate lumbar intervertebral disk degeneration, especially in the L5-S1 intervertebral segment.

Kinematic quantitation of the patellar tendon reflex using a tri-axial accelerometer.

We designed a simple procedure based on the angular speed of the knee joint for quantitating the patellar tendon reflex. The angular speed of the knee joint is calculated from acceleration data generated in response to the tapping force applied to the patellar tendon with a customized tendon hammer and measured using a tri-axial accelerometer placed at the ankle joint. Data were collected and processed using a signal analyzer and a notebook PC. The results obtained using standard equipment were similar to those generated by more elaborate devices. For instance, the time delay (29.6+/-6.0 ms) and the acceleration time (150.8+/-19.5 ms) of the speed response were quite constant for all participants within the range of tapping forces normally applied during physical examinations. Representative relationships between the peak tapping force and the peak angular speed also closely fit with the exponential model (the average coefficient of determination, 0.70; range, 0.43-0.97). In contrast, the mean asymptotic value of the peak angular speed (Omega(pas)) was 160+/-67 degrees/s for spastic individuals, compared with only 72+/-21 degrees/s for healthy individuals. The important features of this method are portability, ease of use, and non-constraint of solicited reflex responses.