The Pain Crisis: Interventional Radiology's Role in Pain Management.

Pain is a complex syndrome that is difficult to treat. The increasing numbers of patients living with chronic diseases has led to increasing pain management needs and the rise of opioid use disorder (OUD) as a major and potentially lethal public health concern. Treatment of chronic pain with prescription opioids alone is not always successful, and a multidisciplinary approach is paramount to address the needs of patients at risk of developing or suffering from OUD. Interventional radiologists trained to perform minimally invasive procedures with negligible downtime and postprocedure pain can help stem the tide of opioid-related deaths and disability. This article reviews a wide range of minimally invasive procedures, including vertebral augmentation, sacroplasty, thermal ablation of osseous metastasis, nerve blocks, and gonadal vein embolization, that interventional radiologists are now using successfully to treat chronic pain. The evidence to support use of such procedures is highlighted. This article also briefly discusses emerging techniques such as arterial embolization and ablation for knee and shoulder osteoarthritis that have not yet been fully tested but exhibit strong potential in chronic pain management. By reducing opioid use in patients suffering from chronic pain, these minimally invasive procedures can potentially prevent escalation to OUD.

The Radiologist's Primer to Imaging the Noncuff, Nonlabral Postoperative Shoulder.

Many radiologists are familiar with the preoperative imaging assessment of patients with labral tears, rotator cuff abnormalities, and end-stage arthritis, as well as the subsequent primary reconstructions and repairs commonly encountered in routine clinical management. However, the second-line surgical procedures and augmentation procedures performed for refractory or recurrent shoulder instability and the extra-articular surgical procedures of the shoulder girdle may challenge even the most experienced musculoskeletal radiologist. Knowledge of the indications, surgical techniques, expected postoperative imaging appearance, and complications of these uncommon shoulder girdle reconstructions and repairs will aid the radiologist in both the pre- and postoperative assessment of the injured shoulder. This article is divided into two parts. In the first part, procedures performed for shoulder instability are addressed, including capsular shift, Bristow-Latarjet coracoid transfer, remplissage, and humeral head allografts. In the second part, the imaging findings of extra-articular procedures of the shoulder girdle are reviewed, including biceps tenodesis, os acromiale fixation, and coracoclavicular ligament reconstruction. ©RSNA, 2017.

Quadriceps Tendon Autograft ACL Reconstruction With Suture Tape Augmentation: Safe Results Based on Minimum 2-Year Follow-up MRI.

Background: The potential intra-articular effects of ≥1 year after anterior cruciate ligament reconstruction (ACLR) with independent suture tape augmentation (STA) are not fully understood. Purpose: To investigate whether incorporating suture tape in an all-soft tissue quadriceps tendon autograft (QTA) ACLR leads to satisfactory patient outcomes while having no intra-articular side effects as determined by magnetic resonance imaging (MRI). Study Design: Case series; Level of evidence, 4. Methods: Included were 25 patients with a mean age of 19.9 years (95% CI, 17.3-22.5 years) who underwent QTA ACLR with STA between 2016 and 2019. All patients underwent MRI at ≥1 year postoperatively and had at least a 2-year follow-up (mean, 28 months [95% CI, 26.5-29.5 months]) that included physical examination with anterior laxity testing with KT-1000 arthrometer, radiographs, and patient-reported outcome measures (PROMs). At the final follow-up, the minimal clinically important difference (MCID) and the Patient Acceptable Symptom State (PASS) for applicable PROMs were applied to each patient. Postoperative graft and joint integrity were assessed using the Howell classification and the MRI Osteoarthritis Knee Score (MOAKS) joint effusion/synovitis grade. The Mann-Whitney U test for continuous variables and the chi-square or the Fisher exact test for categorical variables were used for statistical analyses. Results: The MRI assessment of the grafts demonstrated intact grafts in all patients. Overall, 96% of patients demonstrated grades 0 or 1 MOAKS for joint effusion/synovitis. All patient outcomes significantly improved from preoperatively to the final follow-up (P < .001), except for the Marx score, which decreased significantly (14.2 [95% CI, 12.7-15.8] vs 9.72 [95% CI, 7.3-12.2]; P = .0014). At least 68% of the patients achieved the MCID threshold, and 92% achieved the PASS threshold for all applicable PROMs. Conclusion: QTA ACLR with STA did not demonstrate adverse intra-articular changes on MRI at ≥1 year postoperatively. In addition, STA did not appear to negatively affect PROMs.

The Lateral Knee Radiograph: A Detailed Review.

Initial imaging evaluation for a variety of knee pathologies often begins with a radiographic series. Depending on the specific indication, this will include at least two different projections of the knee. In most cases, these are the anteroposterior and lateral radiographs of the affected knee, and sometimes with the contralateral knee for comparison. Typically, knee pathologies visible on lateral view can also be appreciated on the anteroposterior view. However, several pathologic processes occur in anatomic locations typically obscured on other projections because of superimposed osseous structures. Examples of these pathologies include injuries involving the quadriceps or patellar tendons, avulsion fractures involving anterior or posterior structures, and many soft-tissue injuries. Knowledge of the relevant anatomy and typical pathologies typically visualized on the lateral radiograph of the knee is imperative to avoid overlooking these disease processes.

ACR Appropriateness Criteria® Imaging After Shoulder Arthroplasty: 2021 Update.

Shoulder arthroplasty is a common orthopedic procedure with a complication rate reported to be as high as 39.8% and revision rates as high as 11%. Symptoms related to postoperative difficulties include activity-related pain, decreased range of motion, and apprehension. Some patients report immediate and persistent dissatisfaction, although others report a symptom-free postoperative period followed by increasing pain and decreasing shoulder function and mobility. Imaging plays an important role in diagnosing postoperative complications of shoulder arthroplasties. The imaging algorithm should always begin with radiographs. The selection of the next imaging modality depends on several factors, including findings on the initial imaging study, clinical suspicion of an osseous versus soft-tissue injury, and clinical suspicion of infection.The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Demystifying Sacral Masses: A Pictorial Review.

The sacrum is a triangular shaped bone made up of five fused vertebral bodies. It is composed of bone, cartilage, marrow elements as well as notochord remnants and is a common site for both benign and malignant (primary and secondary) tumors. Familiarity with the imaging features and clinical presentations of sacral bone tumors could be helpful in narrowing the differential diagnosis. Magnetic resonance imaging and computed tomography are the preferred imaging modalities for evaluating sacral masses. This pictorial review will highlight imaging features of common sacral tumors with pathologic correlation. Additionally, this article will review some critical principles and helpful tips to successfully biopsy these lesions.

lessen encodes a zebrafish trap100 required for enteric nervous system development.

The zebrafish enteric nervous system (ENS), like those of all other vertebrate species, is principally derived from the vagal neural crest. The developmental controls that govern the specification and patterning of the ENS are not well understood. To identify genes required for the formation of the vertebrate ENS, we preformed a genetic screen in zebrafish. We isolated the lessen (lsn) mutation that has a significant reduction in the number of ENS neurons as well as defects in other cranial neural crest derived structures. We show that the lsn gene encodes a zebrafish orthologue of Trap100, one of the subunits of the TRAP/mediator transcriptional regulation complex. A point mutation in trap100 causes a premature stop codon that truncates the protein, causing a loss of function. Antisense-mediated knockdown of trap100 causes an identical phenotype to lsn. During development trap100 is expressed in a dynamic tissue-specific expression pattern consistent with its function in ENS and jaw cartilage development. Analysis of neural crest markers revealed that the initial specification and migration of the neural crest is unaffected in lsn mutants. Phosphohistone H3 immunocytochemistry revealed that there is a significant reduction in proliferation of ENS precursors in lsn mutants. Using cell transplantation studies, we demonstrate that lsn/trap100 acts cell autonomously in the pharyngeal mesendoderm and influences the development of neural crest derived cartilages secondarily. Furthermore, we show that endoderm is essential for ENS development. These studies demonstrate that lsn/trap100 is not required for initial steps of cranial neural crest development and migration, but is essential for later proliferation of ENS precursors in the intestine.