George C. Chang Chien

Ultrasound Guidance for Technically Challenging Intrathecal Baclofen Pump Refill: Three Cases and Procedure Description.

ABSTRACTIntrathecal baclofen (ITB) therapy is a common treatment used to reduce spasticity due to neurologic disorders and injuries. A variety of factors can increase the difficulty of ITB pump refill. Excess subcutaneous fat overlying the pump, spasticity, suboptimal positioning, pump rotation or inversion, and scar formation over the reservoir fill port can create challenges during pump refill. As a result, multiple unsuccessful attempts at accessing the reservoir fill port can be painful and increase the risk of infection, particularly when repeat skin puncture is required. Blind attempts to refill a pump in challenging cases may also result in subcutaneous injection or pocket fill, resulting in a potentially fatal baclofen withdrawal syndrome. We describe 3 successful ITB pump refills in technically challenging cases when using ultrasound guidance. This represents an innovative approach to using ultrasound guidance to facilitate ITB refill in adults with intractable spasticity. We present these new clinical data with a literature review of potential complications related to inaccurate pump refill procedures and discuss the utility of ultrasound guidance for preventing such adverse events.

Ultrasound Guidance in Interventional Pain Medicine

Ultrasound has experienced explosive growth in popularity for advanced imaging in interventional pain management and has many distinct advantages over surface-based landmark injection techniques as well as fluoroscopy. Ultrasound benefits from real-time needle imaging and is valuable in avoiding sensitive soft tissue structures such as nerves, vascular structures, and viscous which are not visualized with fluoroscopy. The lack of ionizing radiation exposures makes it more popular for both diagnostic and therapeutic image-guided pain injections. This chapter provides a brief introduction to the use of ultrasound in interventional pain management.

Chronic Pain Rehabilitative Programs

The multidimensional experience of chronic pain results in individualized perceptions and coping mechanisms that reflect the complex biopsychosocial aspects of a patient in chronic pain. Interdisciplinary pain rehabilitation utilizes the biopsychosocial model of care which approaches health as best understood in terms of a combination of biological, psychological, and social factors rather than purely in biological terms. Dedicated functional restoration programs often have a defined duration and schedule of daily activities. Interventional pain management techniques such as sympathetic blocks for complex regional pain syndrome may be appropriate to facilitate physical and occupational therapies. This chapter provides an introduction and overview of chronic pain rehabilitation.

History and Physical Evaluation of Headache

The evaluation of headache begins with ruling out a health or life-threatening cause. If concern is identified, the workup must progress rapidly. If suspicion is alleviated, a reasonable approach involves determining whether symptoms are related to a benign secondary headache disorder versus a primary headache disorder. Headaches may resolve without further need for treatment if a secondary cause of headache can be identified and eliminated. Alternatively, if symptoms appear to be related to a primary headache disorder, establishing a correct diagnosis is vital to subsequently developing a treatment plan.

Central Poststroke Pain Syndrome

Pain is a common complication in the poststroke population. Central poststroke pain syndrome (CPSP) is a type of central neuropathic pain characterized by dysesthesia and allodynia on the side contralateral to the stroke. The quality is most commonly burning or aching, though it may also be described as lacerating or pricking. The time course is variable and can be episodic or continuous. In order to accurately diagnose CPSP, the physician must eliminate other peripheral causes of pain, ranging from musculoskeletal to rheumatologic to peripheral neuropathic (diabetes especially), and must make sure that the site of cerebral lesion is consistent with the distribution of suspected CPSP. This chapter provides a brief overview of the diagnosis and treatment of central poststroke pain syndrome.

Anatomy of the Spine

Keen understanding of spinal anatomy is necessary for accurate diagnosis of painful spine conditions and safe undertaking of interventional spine procedures. This chapter provides an overview of the anatomy of the vertebrae, spinal cord, and vascular supply. A review of common pathological symptoms is provided as well as anatomical considerations for safe interventional spine procedures.

Indications for/Interpretation of Electrodiagnostic Testing

Electrodiagnostic testing is an extension of the physical exam and is dynamic, assessing the real-time function of nerves and muscles. Standard electrodiagnostic testing includes nerve conduction studies and electromyography. These studies are sensitive in the diagnosis of peripheral nervous system disease. This chapter provides an overview of electrodiagnostic testing.

Physical Therapy in the Management of Chronic Pain

A multifaceted and interdisciplinary approach to chronic pain utilizing conservative modalities such as physical and occupational medicine helps facilitate functional restoration, decrease pain, and improve return-to-work rates. Addressing mobility and preventing and correcting deformity can not only slow the progression of disease and decrease pain but can also substantially improve quality of life. Individualized therapy programs should be designed and overseen by medical providers and implemented by physical therapists. By specifically addressing muscle strength, flexibility, neuromuscular control, myofascial dysfunction, functional mobility, endurance, balance, and locomotion, patients can maximize function and ultimately better manage their chronic pain.

Ultrasonography Leads to Accurate Diagnosis and Management of Painful Acromioclavicular Joint Cyst.

Acromioclavicular joint (ACJ) cysts are uncommon causes of shoulder pain. Type 1 ACJ cysts are limited to the ACJ and form in the presence of intact rotator cuff musculature, while type 2 cysts form secondary to biomechanical instability following rotator cuff tear or rupture.