Aaron J. Yang

Kissing spine and the retrodural space of Okada: more than just a kiss?

Baastrup (“kissing spine”) disease is characterized by contact by adjacent lumbar spinous processes and the presence of lumbar interspinous bursitis. The formation of an adventitious bursa within the interspinous region has been described previously in a retrospective review of routine lumbar magnetic resonance imaging in which the authors demonstrated the prevalence of interspinous bursitis in 8.2% of the study population [1]. These authors found an association between the formation of an interspinous bursa and the presence of associated degenerative changes such as central canal stenosis, disk bulging, and anterolisthesis. However, whether this bursa formation is the result of mechanical impingement from adjacent spinous processes or the result of degenerative conditions has not been fully characterized. Dr. Kikuzo Okada first described a communication pathway between single-level bilateral cervical facet joints in 1981 [2]. He described an extradural space dorsal to the ligamentum flavum that could connect the interlaminar region, interspinous region, and bilateral facet joints. This communication has been described in the lumbar spine, whereby interventional procedures in a single-sided facet joint have demonstrated flow of contrast material to the contralateral facet joint [3]. Usually “kissing spine” is thought to be caused by touching of approximating lumbar spinous processes during lumbar extension. This touching may create an adventitial bursa irritation within the interspinous ligament at the same level. However, we postulate that kissing spine disease may actually be an early sign of segmental instability. The anteroposterior shearing forces in persons with spondylolisthesis or early mid-range segmental instability may cause a friction moment, resulting in the interspinous formation of a bursa. Alternatively, excessive fluid within the facet joint caused by effusion may leak through the retrodural space of Okada to this region between the spinous processes and accumulate in the interspinous bursa. This bursa formation is different from a posterior facet joint synovial cyst in that the cyst has a contiguous relationship to the adjacent facet joint and is located in close proximity to the joint, whereas the adventitial bursa formation is more posterior within

Conservative Care in Lumbar Spine Surgery Trials: A Descriptive Literature Review

OBJECTIVE To evaluate the degree to which conservative care and failure were specifically defined in studies comparing nonoperative treatment versus surgery for low back pain (LBP) conditions in adults. DATA SOURCES A comprehensive literature search was conducted by an experienced librarian using MEDLINE (PubMed), Embase, Google Scholar, and CENTRAL from January 2003 to June 2014. Endnote bibliographic management application was used to remove duplicates and organize the citations. STUDY SELECTION Prospective, randomized, or cohort trials comparing surgery versus conservative intervention for patients with LBP conditions. Study selection was conducted by 2 independent reviewers. DATA EXTRACTION Three independent reviewers extracted data from each article using a structured data extraction form. Data extracted included type of study, participant characteristics, sample size, description, and duration of conservative care and whether failed conservative care criterion was defined. DATA SYNTHESIS A total of 852 unique records were screened for eligibility; of those, 72 articles were identified for further full-text review. Thirty-four full texts were excluded based on the exclusion criteria, and 38 articles, representing 20 unique studies, were included for qualitative synthesis. Fifteen of the 20 studies defined the duration of conservative care. Only 3 studies defined the dosage of physical therapy sessions, including total number of visits and visit duration. Two studies described medication usage, including the duration and type. No studies specifically defined what constituted failed conservative therapy. CONCLUSIONS This literature review suggests conservative care is poorly defined in randomized trials, which can lead to ambiguity of research procedures and unclear guidelines for clinicians. Future studies should increase transparency and explicitly define conservative care.

Residency and Beyond: Subspecialization Trends Among Graduating Physiatry Residents and the Musculoskeletal Curriculum.

ABSTRACTPrevious studies and informal surveys have demonstrated a trend among graduating physiatry residents who desired to practice in an outpatient musculoskeletal (MSK)- or spine-type setting. However, there has been no updated information on the current trend among graduating residents as well as sparse information on gauging if current trainees feel prepared on graduation to treat patients with such disorders. This article describes a prospective survey of graduating chief residents during the 2013–2014 academic year in which 72% of chief residents planned to pursue a fellowship. A total of 54% of those chief residents planned to pursue a pain, sports, or spine fellowship. Seventy-five percent of the responding chief residents reported that most of the residents in their program felt that the current amount of required rotations in MSK, sports, spine, or pain medicine was adequate and 85% felt comfortable practicing in a noninterventional spine or MSK position after graduation without a fellowship. The results of this survey provide an updated perspective on the current trends among graduating residents as well as how residents perceive their MSK curriculum. These results may prove useful when evaluating MSK curriculums and shaping resident education to maximize career goals.

Poster 343: Lung Cancer Masquerading as Scapular Pain: A Case Report

Case/Program Description: A 31-year-old man presented with a 5-year history of right hand numbness, weakness, and progressive pain after a motorcycle crash with subsequent humerus fracture requiring intramedullary rod placement. On examination, the patient had a claw hand deformity and atrophy of the interosseous muscles. He was unable to extend his index through small fingers, and had decreased sensation to light touch on the medial hand. He had positive Froment and Wartenberg signs. The patient was referred for electrodiagnostic testing. Setting: Tertiary academic medical center Results: Electrodiagnostic testing revealed a severe right ulnar neuropathy above the elbow at the level of the mid-arm. Ulnar motor nerve conductions to the abductor digiti minimi revealed distal latency of 3.4 ms, amplitude of 1.2 mV, and conduction velocities of 35 m/s (below-elbow to wrist), 37 m/s (above-elbow to below-elbow), and 23 m/s (axilla to above-elbow). There was spontaneous activity and diminished recruitment in all ulnar-innervated muscles tested on needle EMG. Subsequent ultrasound of the ulnar nerve revealed two separate focal nerve enlargements above the elbow consistent with neuromas. At 8 cm proximal to the medial epicondyle, the ulnar nerve cross-sectional area was 26 mm, and at 14 cm proximal to the medial epicondyle, the ulnar nerve cross-sectional area was 71 mm (normal 10 mm). The patient underwent right ulnar nerve neurolysis as well as Bunnell transfers and a pinch plasty. Discussion: This case highlights the added diagnostic utility of ultrasound in conjunction with electrodiagnostic testing. With EMG/NCS alone, definitively identifying the presence of the two separate ulnar nerve lesions/neuromas above the elbow would be challenging. The findings significantly affected the subsequent surgical planning. Conclusions: Ultrasound in conjunction with electrodiagnostic testing can provide additional diagnostic utility, particularly in the identification and management of neuromas-in-continuity. Level of Evidence: Level V

Feasibility of a Biomechanically-Assistive Garment to Reduce Low Back Loading During Leaning and Lifting

Goal: The purpose of this study was: 1) to design and fabricate a biomechanically-assistive garment which was sufficiently lightweight and low-profile to be worn underneath, or as, clothing, and then 2) to perform human subject testing to assess the ability of the garment to offload the low back muscles during leaning and lifting. Methods: We designed a prototype garment which acts in parallel with the low back extensor muscles to reduce forces borne by the lumbar musculature. We then tested eight healthy subjects while they performed common leaning and lifting tasks with and without the garment. We recorded muscle activity, body kinematics, and assistive forces. Results: The biomechanically-assistive garment offloaded the low back muscles, reducing erector spinae muscle activity by an average of 23–43% during leaning tasks, and 14–16% during lifting tasks. Conclusion: Experimental findings in this study support the feasibility of using biomechanically-assistive garments to reduce low back muscle loading, which may help reduce injury risks or fatigue due to high or repetitive forces. Significance: Biomechanically-assistive garments may have broad societal appeal as a lightweight, unobtrusive, and cost-effective means to mitigate low back loading in daily life.

Patellar Dislocations: Review of Current Literature and Return to Play Potential

Acute patellar dislocation is a common cause of traumatic hemarthrosis and is associated with multiple anatomical abnormalities including patella alta, trochlea dysplasia, and malalignment of lower limbs. The medial patellofemoral ligament (MPFL) stabilizes the patella in the early flexion or terminal extension and ruptures in most of first-time patellar dislocations. Thorough radiological evaluations of the MPFL and predisposing anatomical properties are required for the planning of management of recurrent instability. Conservative treatment is the mainstay management of first-time patellar dislocation and achieves good to excellent outcome in most of the patients. Surgery is indicated for recurrent patellar dislocations and first-time patellar dislocations complicated by osteochondral injuries or major MPFL injuries with high functional demand. Return to sports requires painless full range of motion and symmetrical muscle strength in addition to focusing on sport-specific training. Home exercise and behavior modifications in ADLs are important to decrease the reoccurrence of patellar dislocation/subluxation.

Effect of pre-injection opioid use on post-injection patient-reported outcomes following epidural steroid injections for radicular pain

BACKGROUND CONTEXT Chronic opioid therapy is associated with worse patient-reported outcomes (PROs) following spine surgery. However, little literature exists on the relationship between opioid use and PROs following epidural steroid injections for radicular pain. PURPOSE We evaluated the association between pre-injection opioid use and PROs following spine epidural steroid injection. STUDY DESIGN This study is a retrospective analysis of a prospective longitudinal registry database. PATIENT SAMPLE A total of 392 patients within our database who were undergoing epidural steroid injections (ESIs) at our institution for degenerative structural spine diagnoses and met our inclusion criteria were included in this study. OUTCOME MEASURES Patient-reported outcomes for disability (Oswestry Disability Index/Neck Disability Index [ODI/NDI)]), quality of life (EuroQol-5D [EQ-5D]), and pain (Numerical Rating Scale scores for back pain, neck pain, leg pain, and arm pain [NRS-BP/NP/LP/AP]) were assessed at baseline and at 3 and 12 months post-injection. METHODS Multivariable proportional odds logistic regression models were created to examine the relationship between pre-injection opioid use and post-injection PROs. A logistic regression with Bayesian Markov chain Monte Carlo parameter estimation was used to investigate a possible cutoff value of pre-injection opioid use above which the effectiveness of ESI (as measured by minimum clinically important difference [MCID] for ODI/NDI) decreases. RESULTS A total of 276 patients with complete 12-month follow-up following ESI were analyzed. The mean pre-injection daily morphine equivalent amount (MEA) was 14.7 mg (95% confidence interval [CI] 12.4 mg-19.1 mg) for the cohort. Pre-injection opioid use was associated with slightly higher odds of worse disability (odds ratio [OR] 1.03, p=.03) and leg/arm pain (OR 1.01, p=.04) scores at 3 months post-injection only. No significant association between pre-injection opioid use and MCID for ODI/NDI was found, although a cutoff of 55.5 mg/day might serve as a significant threshold. CONCLUSION Increased pre-injection opioid use does not impact long-term outcomes after ESIs for degenerative spine diseases. A pre-injection MEA around 50 mg/day may represent a threshold above which the 3-month effectiveness of ESI for back- and neck-related disability decreases. Epidural steroid injection is an effective treatment modality for pain in patients using opioids, and can be part of a multimodal strategy for opioid independence.

Physical Medicine and Rehabilitation: Physical Modalities, Orthoses, Assistive Devices, and Manipulation

Indications for heat are to provide analgesia, contracture reduction, decrease joint stiffness, increase collagen elasticity, and hyperemia in the setting of a chronic injury. The use of heat as a therapeutic modality is based on the physical properties of conduction, convection, conversion, and radiation. The therapeutic range of heat is 40–45 °C and is commonly maintained for about 5–30 min [1].

Nerve Injuries in Sports

Abstract The field of sports medicine encompasses a broad spectrum of injuries. Nerve injuries to an athlete require special attention because they could not only affect a player’s performance but also lead to further injury either from continuous compression or repeated trauma. Most treatments are conservative in nature, and early recognition and diagnosis can lead to speedier recovery and return to activity in the selected sport. This chapter discusses the more common types of nerve injuries seen in the athletic population by considering them as occurring in the upper and lower extremities.