Botulinum toxin injections for the treatment of neurogenic thoracic outlet syndrome: A systematic review.

Botulinum toxin (BTX) injections into the musculature surrounding the brachial plexus have been examined as a potential treatment for neurogenic thoracic outlet syndrome (nTOS). This systematic review identified 15 publications, of which one was a randomized controlled trial. BTX injections performed with ultrasound or electromyographic guidance, and with the inclusion of the pectoralis minor muscle, in addition to the anterior and/or middle scalenes, tended to provide greater symptom improvement and may predict response to first rib resection. Importantly, most studies were of low quality; thus, the results should be interpreted with caution. Further high-quality studies are needed to confirm these findings.

The effectiveness of intradiscal corticosteroid injection for the treatment of chronic discovertebral low back pain: a systematic review.

OBJECTIVE: Determine the effectiveness of intradiscal corticosteroid injection (IDCI) for the treatment of discovertebral low back pain. DESIGN: Systematic review. POPULATION: Adults with chronic low back pain attributed to disc or vertebral end plate pain, as evidenced by positive provocation discography or Modic 1 or 2 changes on magnetic resonance imaging. INTERVENTION: Fluoroscopically guided or computed tomography-guided IDCI. COMPARISON: Sham/placebo procedure including intradiscal saline, anesthetic, discography alone, or other active treatment. OUTCOMES: Reduction in chronic low back pain reported on a visual analog scale or numeric rating scale and reduction in disability reported by a validated scale such as the Oswestry Disability Index. METHODS: Four reviewers independently assessed articles published before January 31, 2023, in Medline, Embase, CENTRAL, and CINAHL. The quality of evidence was evaluated with the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) framework. The risk of bias in randomized trials was evaluated with the Cochrane Risk of Bias tool (version 2). RESULTS: Of the 7806 unique records screened, 6 randomized controlled trials featuring 603 total participants ultimately met the inclusion criteria. In multiple randomized controlled trials, IDCI was found to reduce pain and disability for 1-6 months in those with Modic 1 and 2 changes but not in those selected by provocation discography. CONCLUSION: According to GRADE, there is low-quality evidence that IDCI reduces pain and disability for up to 6 months in individuals with chronic discovertebral low back pain as evidenced by Modic 1 and 2 changes but not in individuals selected by provocation discography. STUDY REGISTRATION: PROSPERO (CRD42021287421).

Sonographic Assessment of Asymptomatic Patellar and Achilles Tendons to Predict Future Pain: A Systematic Review and Meta-analysis.

OBJECTIVE: Patients with clinical tendinopathy often demonstrate significant abnormalities with ultrasound (US) imaging. Tendon abnormalities likely precede pain in these patients. The purpose of this review was to systematically evaluate the available literature regarding the utility of US imaging as a method to predict Achilles and patellar tendon pain. DESIGN: Systematic review and meta-analysis. Inclusion criteria were as follows: prospective studies of Achilles and patellar tendon pain development with baseline US measurements, follow-up clinical measurements, and English-language studies published after 2000. Exclusion criteria were prior rupture or surgery and presence of rheumatologic disorder. SETTING: N/A. PATIENTS: Athletes without Achilles or patellar tendon pain at baseline. INTERVENTIONS: N/A. MAIN OUTCOME MEASURES: Risk ratios (RRs) were identified for the development of pain in those with Achilles or patellar tendon sonographic abnormalities. RESULTS: This review of 16 studies included 810 Achilles and 1156 patellar tendons from a variety of sports and demonstrated that the RR for pain development from abnormal Patellar and Achilles tendons was 6.07 [95% confidence interval (CI), 2.88-12.81; P < 0.001] and 3.96 [95% CI, 2.21-7.09; P < 0.001], respectively. The positive and negative predictive values of an abnormal US finding were 27.2% and 92.0% for the Achilles tendon and 27.2% and 93.5% for the patellar tendon, respectively. CONCLUSIONS: This systematic review and meta-analysis identified that the use of asymptomatic US scanning of the Achilles or patellar tendon has a low positive predictive value but a high negative predictive value for the future development of pain.

The influence of a single 30-pitch session on elbow laxity in adolescent and collegiate baseball pitchers.

BACKGROUND: Ulnar collateral ligament (UCL) injuries are a source of significant injury among baseball players, and are increasingly evaluated under ultrasound. The purpose of this study is to determine the effect of a single session of pitching upon UCL thickness and laxity via a cross sectional, controlled ultrasonographic study. We hypothesize that a single session of pitching will cause the ulnar collateral ligament to thicken and become more lax. METHODS: This was a cross sectional comparative study of collegiate and high school pitchers. Pitchers underwent an ultrasonographic assessment of the UCL before and after a thirty-pitch bullpen warm-up. Laxity was measured as the change in the distance between the ulna and the trochlea with and without a 5-pound weight held in hand with the elbow at 30° of flexion. Pre- and post-throwing UCL thickness and medial laxity were statistically compared with paired tests. RESULTS: Our study included 15 pitchers, 8 collegiate and 7 high school level athletes. All played baseball at least 6 days a week, and nearly all played for at least 10 months a year. Pitchers reported a peak velocity of 89 ± 6 (77 to 98) miles per hour. In the prior season, these pitchers pitched 56 ± 33 (10 to 120) games, throwing 62 ± 34 (25-140) pitches per game on average. After throwing, there was significantly less UCL laxity (P = .013). Post-throwing laxity was significantly positively correlated with both peak pitch velocity (P = .009) and an average number of pitches thrown per game (P = .10). CONCLUSION: Throwing 30 pitches significantly decreases medial elbow laxity with stress, possibly due to flexor-pronator activation. Post-throwing medial laxity is correlated with both peak pitch velocity and average number of pitches thrown per game. Future studies should be conducted to determine the number of throws at which laxity begins to increase, as this may provide a workload management guideline for injury prevention.

A "Dry Tap" in Prosthetic Joint Infection Workup of Total Hip Arthroplasty Is Not Reassuring.

BACKGROUND: Synovial fluid analysis is important in diagnosing prosthetic joint infection (PJI). The rate of culture-positive PJI in patients who have a dry tap of a total hip arthroplasty (THA) is not well described. METHODS: We reviewed all image-guided THA aspirations, performed from 2014 to 2021 at a single academic institution. Aspirations were categorized as successful (≥ 0.5 mL) or unsuccessful (< 0.5 mL, "dry tap"). We analyzed culture data on all repeat aspirations and revision surgeries performed within 90 days of the initial dry tap. RESULTS: We reviewed 275 consecutive attempted THA aspirations of which 100 (36.4%) resulted in a dry tap. The dry tap cohort had a significantly higher percentage of fluoroscopic-guided aspirations (64%) and fewer ultrasound-guided aspirations (36%) compared to the successful aspiration cohort (48.9% fluoroscopic, 53.1% ultrasound, P = .0061). Of the 100 patients who have dry taps, 48 underwent revision surgery within 90 days of the initial dry tap, and 15 resulted in 2 or more positive cultures. The rate of PJI defined by MusculoSkeletal Infection Society major criteria in the dry tap cohort was 16.0%. CONCLUSIONS: Attempted aspiration of a THA resulted in a dry tap 36.4% of the time. Of those patients who had a dry tap, 16.0% were subsequently found to have PJI based on MusculoSkeletal Infection Society major criteria. Therefore, a "dry tap" does not exclude the diagnosis of infection and should not be considered reassuring for the absence of PJI.

Sonographic peripheral nerve cross-sectional area in adults, excluding median and ulnar nerves: A systematic review and meta-analysis.

INTRODUCTION/AIMS: Although electromyography remains the "gold standard" for assessing and diagnosing peripheral nerve disorders, ultrasound has emerged as a useful adjunct, providing valuable anatomic information. The objective of this study was to conduct a systematic review and meta-analysis evaluating the normative sonographic values for adult peripheral nerve cross-sectional area (CSA). METHODS: Medline and Cochrane Library databases were systematically searched for healthy adult peripheral nerve CSA, excluding the median and ulnar nerves. Data were meta-analyzed, using a random-effects model, to calculate the mean nerve CSA and its 95% confidence interval (CI) for each nerve at a specific anatomical location (= group). RESULTS: Thirty groups were identified and meta-analyzed, which comprised 16 from the upper extremity and 15 from the lower extremity. The tibial nerve (n = 2916 nerves) was reported most commonly, followed by the common fibular nerve (n = 2580 nerves) and the radial nerve (n = 2326 nerves). Means and 95% confidence interval (CIs) of nerve CSA for the largest number of combined nerves were: radial nerve assessed at the spiral groove (n = 1810; mean, 5.14 mm2 ; 95% CI, 4.33 to 5.96); common fibular nerve assessed at the fibular head (n = 1460; mean, 10.18 mm2 ; 95% CI, 8.91 to 11.45); and common fibular nerve assessed at the popliteal fossa (n = 1120; mean, 12.90 mm2 ; 95% CI, 9.12 to 16.68). Publication bias was suspected, but its influence on the results was minimal. DISCUSSION: Two hundred thirty mean CSAs from 15 857 adult nerves are included in the meta-analysis. These are further categorized into 30 groups, based on anatomical location, providing a comprehensive reference for the clinician and researcher investigating adult peripheral nerve anatomy.

Radiofrequency Ablation of the Infrapatellar Branch of the Saphenous Nerve for the Treatment of Chronic Anterior Inferomedial Knee Pain.

INTRO: Genicular nerve radiofrequency ablation (GNRFA) is an effective treatment for chronic knee pain related to osteoarthritis. It is often utilized when conservative management has failed and patients wish to avoid arthroplasty, are poor surgical candidates due to comorbid medical conditions, or in those suffering from persistent pain after arthroplasty. The classic targets for GNRFA include the superior lateral genicular nerve, superior medial genicular nerve, and inferior medial genicular nerve but multiple anatomic studies have demonstrated additional sensory innervation to the knee. OBJECTIVE: In this research article, we propose an image-guided technique that can safely target the infrapatellar branch of the saphenous nerve which also provides sensory innervation to the anterior capsule. PROPOSAL: The proposed technique includes variations for conventional bipolar radiofrequency ablation, cooled radiofrequency ablation, dual-tined bipolar radiofrequency ablation, and monopolar radiofrequency ablation using a long axis approach. The described technique is based on updated anatomic studies and takes into account safety concerns such as thermal risk to the skin and/or pes anserine tendons and breaching of the synovial cavity. CONCLUSION: Future clinical research should be performed to confirm the safety and effectiveness of this specific approach.

Prevalence of Sonographic Achilles Tendon, Patellar Tendon, and Plantar Fascia Abnormalities in Division I Collegiate Athletes From a Variety of Sports.

OBJECTIVE: This study aimed to determine the prevalence of ultrasound abnormalities in the Achilles tendon, patellar tendon, and plantar fascia among a large cohort of collegiate student-athletes. DESIGN: Observational cross-sectional study. SETTING: Three Division I institutions. PARTICIPANTS: 243 student-athletes participated in this study. Exclusion criteria included those younger than 18 years or who underwent prior surgery/amputation of structures, including anterior cruciate ligament (ACL) surgeries with patellar tendon grafts. INTERVENTIONS: Ultrasound examination of the Achilles tendon, patellar tendon, and plantar fascia of each leg was performed. An experienced sonographer reviewed each tendon video in a blinded manner, with a separate experienced sonographer separately reviewing to establish inter-rater reliability. MAIN OUTCOME MEASURES: The primary outcome measured was the presence of any sonographic abnormality including hypoechogenicity, thickening, or neovascularity. RESULTS: Ultrasound abnormalities were identified in 10.1%, 37.2%, and 3.9% of all Achilles tendons, patellar tendons, and plantar fasciae, respectively. Abnormalities were significantly associated with the presence of concurrent pain for all structures (P < 0.01). Specifically, athletes with sonographic abnormalities were approximately 4 times [relative risk (RR) = 4.25; 95% confidence interval (CI), 2.05-8.84], 6 times (RR = 5.69; 95% CI, 2.31-14.00), and 5 times (RR = 5.17; 95% CI, 1.76-15.25) more likely to self-report pain in the Achilles tendon, patellar tendon, and plantar fascia, respectively. CONCLUSIONS: This multi-institutional study completed at 3 Division I institutions is the largest study of its kind to identify the prevalence of sonographic abnormalities in the Achilles tendon, patellar tendon, and plantar fascia among collegiate student-athletes of various sports.

Sports Medicine Physician Decision-Making, Practice Changes, and Mental Health During the Early Phase of the SARS-CoV-2 Global Pandemic.

OBJECTIVE: The SARS-CoV-2 pandemic has had a profound effect on the healthcare system. This study aimed to identify its effects on sports medicine physicians during the early phase of this pandemic. DESIGN: Survey study. SETTING: Sports medicine providers. PARTICIPANTS: Physician members of the American Medical Society for Sports Medicine were surveyed between March 25 and April 4, 2020. A total of 810 responses were obtained from 2437 physicians who viewed the survey. INTERVENTIONS: The survey consisted of questions examining demographics, prepandemic practice patterns, anxiety and depression screening, and new beliefs and behaviors following government-based medical policy changes resulting from the pandemic. MAIN OUTCOME MEASURES: Changes in clinical volume and treatment practices, Patient Health Questionnaire (PHQ-4). RESULTS: The mean in-person clinic visits reduced to 17.9%, telephone visits to 24.4%, telemedicine (video) visits to 21.8%, and procedural visits to 13.8% of prepandemic practice volume. The mean PHQ-4 scores for physicians were 2.38 ± 2.40. Clinic and procedural volumes were reduced less by male physicians, as well as more experienced physicians, nonphysical medicine and rehabilitation training background, in government or private practice, and in the Southern region of the United States (P < 0.05). Physicians were more likely to reduce their anti-inflammatory (37.8% decreasing vs 6.8% increasing, P < 0.001) and opioid (10.5% vs 6.8%, P = 0.003) prescriptions rather than increase. CONCLUSIONS: During the early phase of the SARS-COV-2 pandemic sports medicine physicians reported reducing in-person evaluation, management, and procedure volume by over 80%. Multiple demographic and geographic factors were associated with practice volume changes.

Identification of Knee Effusions With Ultrasound: A Comparison of Three Methods.

OBJECTIVES: To determine whether simple methods can improve identification of suprapatellar joint fluid during sonographic evaluation of the knee. DESIGN: Prospective cohort study. SETTING: Outpatient orthopaedic clinic. PATIENTS: Fifty-two patients were sequentially recruited from an orthopaedic clinic. INTERVENTIONS: Bilateral sonographic evaluation of the suprapatellar recess with static scanning, parapatellar pressure, or patient-initiated quadriceps contraction. MAIN OUTCOME MEASURES: Identification of fluid in the suprapatellar recess. RESULTS: Fifty-two patients (104 knees), consisting of 57 (54.8%) painful knees, were examined. Static scanning identified 45 effusions, parapatellar pressure identified 58 effusions, and quadriceps contraction identified 77 effusions. Quadriceps contraction was superior to parapatellar pressure for identifying an effusion {P < 0.001, proportion ratio [PR] = 1.33 [95% confidence interval (CI) = 1.16, 1.52]}, painful knee effusions [P = 0.036, PR = 1.24 (95% CI = 1.06-1.44)], and painless knee effusions (P = 0.006, PR = 1.50 [95% CI = 1.16-1.93]). Both methods were superior to static scanning. Parapatellar pressure identified effusions in 16.9% of knees not seen on static scanning, whereas quadriceps contraction identified effusions in 54.2% of knees not seen on static scanning. Inter-rater reliability kappa values were 0.771 for static scanning (95% CI = 0.605-0.937), 0.686 for parapatellar pressure (95% CI = 0.531-0.840), and 0.846 for quadriceps contraction (95% CI = 0.703-0.990). CONCLUSIONS: Parapatellar pressure and patient-initiated quadriceps contraction both improve sonographic detection of suprapatellar joint fluid with high inter-rater reliability; however, quadriceps contraction was superior to parapatellar pressure when assessing for grade 1 or occult effusions.

Sonographic Screening of Distance Runners for the Development of Future Achilles and Patellar Tendon Pain.

OBJECTIVE: The 2 primary aims of this study were to identify ultrasonographic tendon abnormalities in asymptomatic runners and to examine the likelihood of developing pain in runners with ultrasound abnormalities compared with those without abnormalities. DESIGN: Longitudinal, prospective cohort study. SETTING: 2019 Salt Lake City Marathon. PARTICIPANTS: Recreational half-marathon and full-marathon runners. ASSESSMENT OF RISK FACTORS: The Achilles and patellar tendons of asymptomatic runners were examined with ultrasound imaging before a running event. Runners were monitored for self-reported outcomes of pain in the examined tendons at 1, 3, 6, and 12 months after the event. MAIN OUTCOME MEASURES: Development of pain based on the presence of asymptomatic tendon abnormalities. RESULTS: One hundred thirty-eight runners (36.2 ± 12.0 years, 49.3% men, and 31.2% full-marathon runners) were included. Ultrasound abnormalities of the Achilles and patellar tendons were identified in 24.6% and 39.1% of the runners before the race, respectively. Ultrasound abnormalities were significantly associated with approximately a 3-fold increase [hazard ratio (HR) = 2.55, P = 0.004] in the hazard of developing pain in the Achilles tendon and patellar tendon (HR = 1.67, P = 0.042) over the year after the race. Positive and negative predictive values of developing pain over the year were 34.1% and 87.2%, respectively, for abnormal findings in the Achilles tendon, and 22.9% and 85.0%, respectively, for the patellar tendon. CONCLUSIONS: The presence of ultrasonographic abnormalities is associated with increased development of pain in the Achilles and patellar tendons within 1 year of a marathon or half marathon.

Postrace Dry Needling Does Not Reduce Subsequent Soreness and Cramping-A Randomized Controlled Trial.

OBJECTIVE: To identify whether a single session of postrace dry needling can decrease postrace soreness and quantity of postrace leg cramps in half-marathon and full-marathon runners. DESIGN: Single-blind, prospective, randomized, controlled trial. SETTING: Finish line of 2018 Salt Lake City Marathon & Half-Marathon. PARTICIPANTS: Runners aged 18 years or older who completed a marathon or half-marathon. INTERVENTIONS: True or sham dry needling of the bilateral vastus medialis and soleus muscles within 1 hour of race completion by 2 experienced practitioners. MAIN OUTCOME MEASURES: The primary outcome measure was numeric pain rating improvements for soreness on days 1, 2, 3, and 7 compared to immediately postrace. Secondary outcome measures included number of postrace cramps and subjective improvement of soreness. RESULTS: Sixty-two runners were included with 28 receiving true and 34 receiving sham dry needling. Objective pain scores showed an increase in pain of the soleus muscles at days 1 and 2 (P ≤ 0.003 and P ≤ 0.041, respectively) in the dry needling group. No differences were seen in postrace pain in the vastus medialis muscles (P > 0.05). No association was seen between treatment group and presence of postrace cramping at any time point (P > 0.05). Subjectively, there was a nonsignificant trend for those receiving dry needling to feel better than expected over time (P = 0.089), but no difference with cramping (P = 0.396). CONCLUSIONS: A single postrace dry needling session does not objectively improve pain scores or cramping compared to sham therapy.

The ulnar collateral ligament responds to stress in professional pitchers.

BACKGROUND: Our purpose with this study was to determine the response of the ulnar collateral ligament (UCL) in professional pitchers after exposure to a season of pitching and to rest during an off-season. METHODS: In a prospective study supported by Major League Baseball, all pitchers within a single professional baseball club were enrolled. An ultrasound of the ligament was then performed by a single fellowship-trained ultrasonographer at the beginning of the season (T1), the end of the season (T2), and the beginning of the following season (T3). We measured the UCL thickness and ulnotrochlear joint opening at 30° of flexion with and without stress. Two ultrasound images were saved. Inter- and intra-rater reliability were determined. A multivariable analysis was conducted. RESULTS: A total of185 total pitchers were included: 94 pitchers at T1, 83 at T2, and 118 at T3. These pitchers had 12 [7, 15] (median [interquartile range]) years of pitching experience and had a peak velocity of 95 [93, 97] miles/hour. Intra- and inter-rater reliability were excellent. The baseline UCL thickness was associated with peak velocity (P = .031) and prior UCL reconstruction (P = .024). After accounting for pitching experience, peak velocity, and prior UCL reconstruction, thickness increased during the season (P = .002) and decreased during the off-season (P = .001). After accounting for these same variables, valgus laxity at 30° increased during the season (P = .002) and decreased during the off-season (P = .029). CONCLUSION: The UCL responds to stress in professional pitchers by becoming thicker and more lax, and responds to rest by becoming thinner and less lax.

The National Interscholastic Cycling Association Mountain Biking Injury Surveillance System: 40,000 Student-Athlete-Years of Data.

ABSTRACT: A web-based injury surveillance system was implemented through a collaboration between University of Utah researchers and the National Interscholastic Cycling Association (NICA) to better understand injury characteristics in mountain biking. Data were collected from NICA leagues during the 2018 and 2019 seasons. Injuries were tracked in 41,327 student-athlete-years, identifying 1750 unique injuries during 1155 injury events. Rider-dependent and rider-independent variables were analyzed. The most commonly reported injuries were concussion (23.6%), injuries to the wrist/hand (22.3%), and shoulder (15.6%). Half of all injury events occurred on downhills. Men and women reported similar yet significantly different injury rates (2.69% and 3.21%, respectively; P = 0.009). Women sustained more lower-limb injuries (37.8% vs 28.3%; P = 0.003). Nearly 50% of crashes resulted in an emergency room visit. Youth mountain bike racing is a rapidly growing sport. Acute traumatic injuries are common. Injury surveillance system data are now being used to inform injury prevention strategies and direct future research.

The Effectiveness of Platelet-Rich Plasma Injection for the Treatment of Suspected Sacroiliac Joint Complex Pain; a Systematic Review.

OBJECTIVE: To determine the effectiveness of platelet-rich plasma (PRP) and bone marrow aspirate concentrate (BMAC) for the treatment of suspected sacroiliac joint complex (SIJC) pain. DESIGN: Systematic review. SUBJECTS: Persons aged ≥18 with suspected SIJC pain. COMPARISON: Sham, placebo procedure, or active standard of care treatment. OUTCOMES: The primary outcome was ≥50% pain improvement, and the secondary outcome was functional improvement of ≥30% at three or more months after the treatment intervention. METHODS: Publications in PubMed, MEDLINE, Embase, Scopus, and Cochrane Databases were reviewed up to April 3, 2019. Randomized or nonrandomized comparative studies and nonrandomized studies without internal controls were included. The Grades of Recommendation, Assessment, Development, and Evaluation system and the joint consensus American Academy of Orthopedic Surgery/National Institutes of Health recommendations were used for quality assessment and reporting standards. RESULTS: Query identified 151 publications; three were appropriate for inclusion. There were no studies of BMAC that met inclusion criteria. There were three eligible PRP studies: one randomized comparative trial (RCT) and two case series. In the single RCT comparing ultrasound-guided PRP with corticosteroid injection for suspected SIJC pain, the PRP group had a significantly increased likelihood of achieving ≥50% improvement of pain at three months (adjusted odds ratio = 37, 95% confidence interval [CI] = 4.65-298.69). Pooled pain outcomes from two studies showed that 28/30, 93% (95% CI = 93-100%), experienced ≥50% pain improvement at three months. CONCLUSIONS: The literature supporting the effectiveness of PRP for SIJC pain is very low-quality according to the GRADE system. Well-designed RCTs and large cohort studies with consistent selection protocols and reporting characteristics are needed to determine the effectiveness of PRP and BMAC for the treatment of SIJC pain.

The Effectiveness of Fluoroscopically Guided Cervical Transforaminal Epidural Steroid Injection for the Treatment of Radicular Pain; a Systematic Review and Meta-analysis.

OBJECTIVE: Determine the effectiveness of fluoroscopically guided cervical transforaminal epidural steroid injection (CTFESI) for the treatment of radicular pain. DESIGN: Systematic review and meta-analysis. SUBJECTS: Persons aged ≥18 years with cervical radicular pain due to disc herniation or degenerative spondylosis. COMPARISON: Sham, placebo procedure, or active standard of care treatment, excluding alternative versions of epidural steroid injection. OUTCOMES: The primary outcome measure was patient-reported improvement in pain of at least 50% from baseline, assessed four or more weeks after the treatment intervention. Secondary outcomes included validated functional assessment tools and avoidance of spinal surgery. METHODS: Randomized or nonrandomized comparative studies and nonrandomized studies without internal control were included. Three reviewers independently assessed publications in the Medline, PubMed, and Cochrane databases up to July 2018. The Grades of Recommendation, Assessment, Development and Evaluation (GRADE) system was used to evaluate risk of bias and overall quality of evidence. A meta-analysis was conducted for comparative measures of effect and for within-group response rates if applicable. RESULTS: There were no studies with an internal comparison group (control group) meeting the review's definition of comparison group. Therefore, comparative measures of effect were not calculated. In cohort studies, pooled response rates were 48% (95% confidence interval [CI] = 34-61%) at one month and 55% (95% CI = 45-64%) at three months. CONCLUSIONS: Approximately 50% of patients experience ≥50% pain reduction at short- and intermediate-term follow-up after CTFESI. However, the literature is very low quality according the GRADE criteria, primarily due to a lack of studies with placebo/sham or active standard of care control comparison groups.

Changes in Interventional Pain Physician Decision-Making, Practice Patterns, and Mental Health During the Early Phase of the SARS-CoV-2 Global Pandemic.

BACKGROUND AND OBJECTIVES: The novel coronavirus outbreak (SARS-CoV-2) began in late 2019 and dramatically impacted health care systems. This study aimed to describe the impact of the early phase of the pandemic on physician decision-making, practice patterns, and mental health. METHODS: An anonymous survey was distributed to physician members of the Spine Intervention Society (SIS) on March 24 and April 7, 2020. Respondents provided information regarding changes in clinical volume, treatment, and mental health (Patient Health Questionnaire [PHQ-4]) before April 10, 2020. RESULTS: Of the 1,430 individuals who opened the survey, 260 completed it (18.2%). Overall clinical and procedural volume decreased to 69.6% and 13.0% of prepandemic volume, respectively. Mean in-person clinic visits were reduced to 17.7% of total prepandemic clinic volume. Ongoing clinical visits were predominantly completed via telemedicine (video) or telephone (74.5%), rather than in-person (25.5%). Telemedicine and telephone visits represented 24.6% and 27.3% of prepandemic clinical volume, respectively. Respondents decreased in-person visits of select groups of high-risk patients by 85.8-94.6%. Significantly more providers reported increasing rather than decreasing prescriptions of the following medications: opioids (28.8% vs 6.2% of providers, P < 0.001), muscle relaxants (22.3% vs 5.4%, P < 0.001), neuropathic pain medications (29.6% vs 3.8%, P < 0.001), and acetaminophen (26.2% vs 4.2%, P < 0.001). Respondents' mean PHQ-4 score was 3.1, with 19% reporting moderate or severe psychological distress. Several demographic factors were significantly associated with practice changes. CONCLUSIONS: The novel coronavirus pandemic dramatically altered the practice and prescribing patterns of interventional pain physicians.

Outcomes of Nonsurgical Treatments for Symptomatic Adult Degenerative Scoliosis: A Systematic Review.

OBJECTIVE: To evaluate the effectiveness of nonsurgical treatments in symptomatic adult degenerative scoliosis (ADS). DESIGN: A systematic literature review. METHODS: PubMed, Web of Science, and The Cochrane Library were searched to identify research published since 1988. Randomized controlled trials (RCTs) and observational cohort studies were eligible if they featured symptomatic ADS patients aged ≥50 who received nonsurgical treatment. Minimum follow-up was six weeks, and outcomes of interest were pain, disability, quality of life, and Cobb angle. Evidence quality per intervention was rated using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system. RESULTS: Six studies were included. Of these, four focused specifically on injections, bracing, or yoga; two involved multiple treatments. One RCT provided evidence for greater effectiveness of transforaminal epidural steroid injection over anesthetic alone in reducing radiating pain and disability. Two single-group retrospective cohort studies lent support for bracing to slow curve progression. One retrospective single-group cohort study suggested an association between yoga and reduced curve progression. Evidence for injections to reduce ADS symptoms was rated as low quality; evidence for bracing and yoga was rated as very low quality. No specific evidence was identified regarding other treatments, including physical therapy and analgesics. CONCLUSIONS: Literature describing the effectiveness of nonoperative treatments in symptomatic ADS is scarce. The quantity and quality of the evidence regarding injections, bracing, and yoga are insufficient to advise for or against the use of these methods to improve outcomes in symptomatic ADS. For these and other nonoperative treatment forms, further research is needed.

The Effectiveness of Spinal Cord Stimulation for the Treatment of Axial Low Back Pain: A Systematic Review with Narrative Synthesis.

OBJECTIVE: Determine the effectiveness of spinal cord stimulation (SCS) for the treatment of axial low back pain (LBP) with or without leg pain. DESIGN: Systematic review. SUBJECTS: Persons aged ≥18 with axial LBP with or without accompanying leg pain. INTERVENTION: Traditional low-frequency, burst, or high-frequency SCS. COMPARISON: Sham, active standard of care treatment, or none. OUTCOMES: The primary outcome was ≥50% pain improvement, and the secondary outcome was functional improvement measured six or more months after treatment intervention. METHODS: Publications in PubMed, MEDLINE, and Cochrane databases were reviewed through September 19, 2019. Randomized or nonrandomized comparative studies and nonrandomized studies without internal controls were included. The Cochrane Risk of Bias Tool and GRADE system were used to assess individual study characteristics and overall quality. RESULTS: Query identified 262 publications; 17 were suitable for inclusion. For high-frequency SCS, the only level 1 study showed that 79% (95% confidence interval = 70-87%) of patients reported ≥50% pain improvement. For low-frequency SCS, the only level 1 study reported no categorical data for axial LBP-specific outcomes; axial LBP improved by a mean 14 mm on the visual analog scale at six months. Meta-analysis was not performed due to study heterogeneity. CONCLUSIONS: According to GRADE, there is low-quality evidence that high-frequency SCS compared with low-frequency SCS is effective in patients with axial LBP with concomitant leg pain. There is very low-quality evidence for low-frequency SCS for the treatment of axial LBP in patients with concomitant leg pain. There is insufficient evidence addressing the effectiveness of burst SCS to apply a GRADE rating.

Gabapentin and Tricyclics in the Treatment of Post-Concussive Headache, a Retrospective Cohort Study.

OBJECTIVE: To examine the association of commonly prescribed post-concussive medications, namely gabapentin and tricyclic antidepressants (TCAs), with symptom reduction after concussion. BACKGROUND: Concussion is a common diagnosis in modern medicine. Many providers use medication to target the residual symptoms of a concussion, with little evidence supporting their efficacy. DESIGN: Retrospective study with longitudinal analysis using mixed-effects and piecewise regression analyses of 277 patients presenting to an academic sports medicine clinic, all of whom were clinically diagnosed with a concussion. Main outcomes were patient-reported headache score (quantitative variable; 0-6) and combined symptom score (quantitative variable; 0-132) from the Post-Concussion Symptom Scale (PCSS). METHODS: Patients self-reported their symptom scores on the PCSS at the time of each clinic visit. Gabapentin or TCAs were prescribed to some patients during their follow-ups for headache treatment, based on physician judgment. Patients were classified into 3 groups: (1) no medication; (2) gabapentin; or (3) TCAs. Follow-up data were evaluated over 1 year. A mixed-effects and piecewise regression analysis were performed to assess long- and short-term effects of medication status. RESULTS: The mixed-effects analysis showed a significant decrease in both headache and symptom scores over time in each medication group and in those not receiving medication (P ≤ .014 for all scenarios, B = -0.005 and -0.08, respectively). Although patients in the 2 medication groups showed significantly higher headache and symptom scores (P < .001), neither medication had a significant effect on longitudinal improvements in the outcome scores. The piecewise regression, however, showed short-term improvements with gabapentin (1.3 points, P = .004) and more sustained improvements with TCAs (3.5 points, P = .006). CONCLUSIONS: Patients recover from a concussion with time, regardless of medication. Gabapentin and TCAs appear to have immediate effects on improving symptom burden, but long-term outcomes show similar improvement compared to those who are not prescribed medication. More rigorous prospective studies are required to better elucidate their efficacy.