Hamilton Chen

mild Procedure for Lumbar Decompression: A Review

Abstract:  Lumbar spinal stenosis (LSS) is characterized by narrowing of the spinal canal with impingement of the spinal cord by surrounding tissues of bones. Current management options for LSS include rest, medications, physical therapy, epidural steroid injections, alternative medicine, and surgical decompression. Because each modality of treatment has its own set of limitations, there is a need for a safe, effective, and cost‐saving treatment for LSS. mild is a minimally invasive procedure for treatment of degenerative LSS with ligamentum flavum hypertrophy through percutaneous decompression of the hypertrophic ligamentum flavum. The effect is debulking of tissue that is a contributor to lumbar canal narrowing with minimal trauma to surrounding tissue. This literature review presents a brief review of the pathophysiology, clinical presentation, and current treatment options for LSS and reviews the current literature regarding the efficacy, safety, and cost‐effectiveness of the mild procedure.

Ultrasound Guided Piriformis Injection with Confirmation of Needle Placement Through Electromyography

Dear Editor: Piriformis syndrome is a controversial topic that consists of a constellation of symptoms that may mimic spondylosis, radiculopathy, sacroiliac joint pain, and facet arthropathy [1]. One of the modalities of piriformis syndrome treatment is direct injection of medication into the piriformis muscle belly [2]. Previous authors have reported various methods in performing piriformis injections: fluoroscopically, motor stimulation, and most recently, ultrasound (US) guidance [3–5]. We describe a case presentation and, to our knowledge, the first report of combined use of US with electromyography (EMG) confirmation of muscle placement for piriformis muscle injection. A 60-year-old male presented to our clinic with lower back, left hip, and left buttock pain for 6 years. The pain was sharp in quality and radiated toward the left lateral buttock and hip. The pain was rated 6/10 at initial presentation and was aggravated by prolonged sitting, squatting, and bending over. Pain was improved with rest. On examination, the patient demonstrated mild tenderness along the left lumbar spine and paraspinal muscles, as well as tenderness to palpation in the left lateral buttock area. Straight leg raise test was positive in the left lower extremity. Motor examination revealed full …

Neuromuscular Ultrasound Application to the Electrodiagnostic Evaluation of Quadrilateral Space Syndrome

Quadrilateral space syndrome (QSS) is a rare neurovascular compression syndrome that results from the compression of the axillary nerve and posterior circumflex humeral artery in the quadrilateral space. Electromyography often is used to evaluate for the presence of neuropathic changes in the deltoid and teres minor in cases of suspected QSS. Needle examination of the teres minor may be challenging because of the muscles small size and proximity to the infraspinatus. In cases in which patients are overweight or have significant teres minor atrophy, localization of the muscle through conventional methods may be extremely difficult. We present a case of an overweight man with posterior shoulder pain who was diagnosed with QSS via the use of a combination of ultrasound and electromyography.

Effect of home exercise program performance in patients with osteoarthritis of the knee or the spine on the visual analog scale after discharge from physical therapy.

The aim of our study was to assess the effect of the frequency of home exercise program (HEP) performance on pain [10-point visual analog scale (VAS)] in patients with osteoarthritis of the spine or knee after more than 6 months discharge from physical therapy (PT). We performed a retrospective chart review of 48 adult patients with a clinical diagnosis of knee or spine osteoarthritis and had been discharged from PT of the spine or the knee for at least 6 months with provision of HEP from a physical therapist. Adult patients who were younger than 50 years of age, taking more than one medication to control pain, participating in worker’s compensation, or had a history of drug abuse were excluded from the study. We recorded patient demographics, pain level (10-point VAS scale), and the number of days that a HEP was performed per week. The mean VAS score of patients who performed 0 days of HEP per week was 6.90. The mean VAS score of patients who performed HEP 1–3 times per week was 6.36. The mean VAS score of patients who performed HEP 4–7 times per week was 5.00. Single-factor analysis of variance analysis indicated a P-value of less than 0.01. Post-hoc comparison of the mean VAS using Fisher’s least significant difference test showed a significant difference between the mean VAS score of 4–7 days per week of HEP versus 0 days per week (P<0.01) and 1–3 days per week (P<0.01) of HEP. There was no significant difference in the mean VAS score between 0 days of HEP and 1–3 days of HEP (P>0.05). Patients who performed 4–7 days per week of HEP had statistically significant lower mean VAS scores than patients who performed 0 days per week of HEP and 1–3 days per week of HEP. Therefore, after 6 months of discharge from PT, patients should be encouraged to perform at least 4 days of HEP per week.

Spinal cord stimulation for treatment of the pain associated with hereditary multiple osteochondromas.

Objective Hereditary multiple osteochondromas (HMO) usually presents with neoplastic lesions throughout the skeletal system. These lesions frequently cause chronic pain and are conventionally treated with surgical resection and medication. In cases where conventional treatments have failed, spinal cord stimulation (SCS) could be considered as a potential option for pain relief. The objective of this case was to determine if SCS may have a role in treating pain secondary to neoplastic lesions from HMO. Case presentation We report a 65-year-old female who previously received both surgical and pharmacological interventions for treating HMO neoplastic pain in the lumbar, pelvis, femur, and tibial regions. These interventions either failed to offer significant pain relief or caused excessive lethargy. A SCS trial was then offered with a dual 16-contact lead trial leading to 70%–80% improvement in pain from baseline and 85% reduction in oxycodone IR intake. This was followed by permanent implantation of two 2×8 contact paddle leads (T7–T8 and T9–T10 interspaces). After 8-week follow-up, settings were further optimized resulting in an additional 30% improvement in pain compared to last visit. At 6-month follow-up, the patient reported continued pain relief. Conclusion This case demonstrates the first successful use of SCS to treat both HMO and nonmalignant neoplastic-related pain. The patient reported pain improvement from baseline, reduced pain medication requirements, and subjective improvement in quality of life. Additionally, this case demonstrates the potential advantage of trialing multiple painful areas with a 16-contact lead in order to avoid multiple trials and placement.

Improving Trainee Competency and Comfort Level with Needle Driving Using Simulation Training.

OBJECTIVE To assess whether a combination of lecture and model simulation improves resident competency and comfort level with needle driving for interventional pain medicine procedures. DESIGN Prospective, observational study. METHOD Trainees who rotated through the University of California, Irvine, outpatient pain medicine clinic were recruited for the study. Subjects were given a brief lecture and completed a survey with questions regarding their level of comfort with interventional pain medicine procedures. This was followed by a timed trial on a training simulator where the objective was to drive a needle to the target. After the trial, the subject was then given a 30-minute practice session with the simulation model. The subject was then asked to repeat the timed trial and complete a post-simulation survey. RESULTS All measures of the level of comfort increased significantly after subjects underwent the simulation training. In addition, subjects were able to significantly decrease their entrance time (P= 0.002), total time (P= 0.033), and vertical (P≤ 0.001) and horizontal deviation (P≤ 0.001) from the final target point after the simulation training. CONCLUSIONS Our study demonstrates that simulation training may improve both trainee comfort level and competency with needle driving. After a brief lecture and a 30-minute training session with the simulator, subjective comfort measures and competency measures (more subjects were able to reach the target, vertical and horizontal deviations from the target decreased) were significantly improved. This suggests that simulation may be a helpful tool in teaching needle driving skills.

Diagnosis and Current Treatments for Sacroiliac Joint Dysfunction: A Review

The sacroiliac joint (SIJ) is a common pain generator for individuals with low back pain. Diagnosis and treatment of sacroiliac joint dysfunction is often a challenge due to the complex anatomy and biomechanics of the joint. In addition, patient presentation is often nonspecific. The purpose of this review article is to provide a concise overview of the relevant anatomy, pathogenesis, diagnosis, and the current conservative as well as interventional treatments for SIJ dysfunction.

Presentation of Rhabdomyolysis in the Autoimmune Variant of Stiff-Person Syndrome

a history of chronic fluoride exposure while working in a factory over 35 years ago, and a previous diagnosis of osteofluorosis. Discussion: Osteofluorosis is a rare condition that results in individuals exposed to high level of fluoride in the air or food/ drink, and results in an array of bony abnormalities such as osteomalacia, osteosclerosis, and/or exostoses. When such bony irregularities occur at humeral heads and near bicepital grooves, repetitive mechanical shears on supraspinatous tendons and proximal long head of biceps tendons in the subacromial space can lead one to the development of patient’s shoulder tendinosis. Conclusions: We present a unique case of atraumatic bilateral supraspinatous and biceps tendinosis secondary to diffuse exostosis of humerus attributed to osteofluorosis.

A Novel Approach to the Ulnar Motor Nerve Conduction Study with Ultrasound Assistance in Patients with Anterior Ulnar Nerve Transposition Surgery

Disclosures: H. Chen, No Disclosures: I Have Nothing To Disclose. Case Description: We present a case series of three patients with a prior history of anterior ulnar nerve transposition surgery who underwent an ulnar motor nerve conduction study (NCS) utilizing ultrasound assistance. Setting: Outpatient Electrodiagnostic Clinic Results or Clinical Course: The NCS was carried out using a Sonosite M-Turbo ultrasound system (Sonosite, Bothell, WA, USA) equipped with a 13-6 MHz multifrequency, linear transducer and a Cadwell Sierra Wave EMG machine (Cadwell, Kennewick, WA, USA). In all three patients, the ulnar nerve was easily localized anterior to the medial epicondyle. The nerve was subsequently mapped to determine the proper below-elbow and above-elbow stimulation sites. Once the nerve was mapped, the nerve conduction study was carried out in a routine manner. All patients tolerated the procedure well. Discussion: Ulnar nerve entrapment at the elbow (cubital tunnel syndrome) is one of the most common compression neuropathies. Surgical treatment of cubital tunnel syndrome typically involves decompression and anterior transposition of the ulnar nerve. After surgical treatment, patients will often be referred for repeat NCS to assess for changes in conduction velocity. However, in a patient with a transposed ulnar nerve, it is technically difficult to localize the proper NCS stimulation sites and mapping of nerve position is performed through multiple submaximal stimulations. In addition, without knowing the true anatomical location of the nerve, it is difficult to obtain accurate measurements of the nerve length. These factors lead to inaccurate conduction velocity studies and increased patient discomfort. We present a case series of a novel approach to ulnar motor NCS with ultrasound assistance. We believe that our approach eliminates the need for mapping of the nerve position with multiple stimuli, giving improved patient comfort. In addition, by knowing the exact course of the transposed nerve, it may result in more accurate measurements of the ulnar nerve length and improved NCS accuracy and efficiency. Conclusions: With a strong anatomy background and appropriate training in this modality, ultrasound may be successfully applied to NCS of the ulnar nerve in patients with a history of an anterior ulnar nerve transposition.

Application of ultrasound to the median sensory and ulnar motor nerve conduction studies: Letters to the Editor

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