Jason L. Zaremski

Risk factors for false positive transcranial motor evoked potential monitoring alerts during surgical treatment of cervical myelopathy.

Study Design. Retrospective consecutive series review. Objective. To examine performance of transcranial motor-evoked potential (TcMEP) monitoring in patients undergoing surgery for cervical myelopathy and potential risk factors for false positive alerts. Summary of Background Data. Although use of TcMEP monitoring has been increasing and has been specifically recommended in patients with cervical myelopathy, rates and risk factors for false positive alerts have not been established. Methods. Intraoperative neuromonitoring data for 52 consecutive patients undergoing surgery for cervical myelopathy were reviewed. All major TcMEP alerts were identified. Comprehensive demographic and clinical data, preoperative imaging studies, operative, and anesthesia records were reviewed. Results. Six of 52 patients (12%) experienced a major TcMEP alert consisting of sustained >80% loss of amplitude. There were no somatosensory-evoked potential (SSEP)-related alerts. In 2 cases, an intraoperative wake-up test was negative and in 3 cases, surgery was completed without a wake-up test and without recovery of TcMEP signals. No new postoperative neurologic deficits were observed in these patients. One patient with new postoperative weakness was correctly predicted by loss of TcMEP signals. No new deficit was observed in the remaining 46 patients. Statistical analysis revealed significantly higher body mass index (28.8 vs. 35.0; P = 0.032) and length of surgery (191 vs. 283 minutes; P = 0.019) in patients with false positive alerts. Conclusion. In this series of cervical myelopathy patients, sensitivity and specificity of TcMEP for detection of clinically significant intraoperative cord injury were 100% and 90%, respectively. Sensitivity and specificity of SSEP were 0% and 100%, respectively. The positive predictive value of a TcMEP alert was 17%. Possible risk factors for false positive TcMEP alerts include obesity and increased length of surgery. This study supports superior sensitivity of TcMEP compared with SSEP monitoring but identifies a relatively high false positive rate even in a selected high-risk cervical myelopathy population when this modality is applied in practice.

Effect of neurocognition and concussion on musculoskeletal injury risk.

Research regarding musculoskeletal injury risk has focused primarily on anatomical, neuromuscular, hormonal, and environmental risk factors; however, subsequent injury risk screening and intervention programs have been largely limited to neuromuscular factors and have faced challenges in both implementation and efficacy. Recent studies indicate that poor neurocognitive performance, either at baseline or in the aftermath of a concussion, is associated with elevated risk of musculoskeletal injury. Despite the relatively limited current understanding regarding the nature of the relationship between different aspects of neurocognitive performance and musculoskeletal injury risk, this is a promising area of research that may yield significant advances in musculoskeletal injury risk stratification, rehabilitation, and prevention.

Does Geographic Location Matter on the Prevalence of Ulnar Collateral Ligament Reconstruction in Collegiate Baseball Pitchers

Background: There has been a significant amount of research in the prevention of throwing injuries. However, one area of research that is lacking is geographic location of play. Warm climates may permit year-round play and increased exposure to throwing arm injury risk. Hypotheses: (1) Pitchers from southern institutions would have greater rates of ulnar collateral ligament reconstruction (UCL-R) compared with pitchers from northern institutions. (2) Pitchers originating from high school teams in warm weather states would have a greater risk of undergoing UCL-R while in college. Study Design: Descriptive epidemiological study. Methods: This study was completed by reviewing publicly obtained records of male collegiate baseball players during the 2008 through 2014 seasons. Data were accessed through online search engines, online baseball media guides, and school websites. Results: A total of 5315 player-years and 2575 pitcher-years were identified. Fifty-eight UCL-R cases were found in collegiate pitchers, 40 of which occurred in the Southeastern Conference (SEC) and 18 in the Big Ten. More injuries (36/58) occurred in pitchers who participated in high school baseball in southern states as compared with northern states (22/58), regardless of location of collegiate participation (χ2 = 28.8, P < .05). The injury rate for pitchers who participated in high school baseball in southern states was 25.3 per 1000 player-years versus 19.1 per 1000 player-years in northern states, with a risk ratio of 1.32 (χ2 = 0.89, P = .35). The injury rate for the SEC versus Big Ten pitchers was 13.3 per 1000 player-years versus 7.8 per 1000 player-years, with a risk ratio of 1.71 (χ2 = 1.45, P = .23). Conclusion: There is a greater likelihood of undergoing UCL-R in the SEC compared with the Big Ten. There is also an increased risk for UCL-R for pitchers who played high school baseball in southern states versus northern states, irrespective of collegiate play location. Clinical Relevance: Pitchers originating from high schools in a warm weather climate may be more likely to undergo UCL-R.

Concussion-like symptom reporting in non-concussed adolescent athletes

Abstract Objective: The primary goals of this study were (1) to report rates of concussion-like symptoms in healthy adolescent student athletes assessed using the Sport Concussion Assessment Tool, 3rd edition (SCAT3) at baseline, (2) to examine rates of psychiatric diagnoses in this population, and (3) to evaluate effects of baseline symptoms on SCAT3 cognitive and balance performance.Methods: 349 adolescent student athletes (245 male) were administered the SCAT3 during pre-participation physical examinations. We described the prevalence rate of student athletes meeting criteria for International Classification of Diseases, 10th revision, post-concussional syndrome (ICD-10 PCS) diagnosis at baseline, and evaluated associations between symptom reporting and demographic/medical history factors using chi-square tests. Rates of self-reported psychiatric diagnosis were compared to general population estimates with one-sample binomial tests. We also compared SCAT3 cognitive and balance performance between adolescents with and without baseline ICD-10 PCS symptoms.Results: Overall, 20.3% of participants met ICD-10 PCS criteria at baseline. Rates were similar across sexes and age groups. We found no statistical association with medical history factors. The proportion of student athletes reporting a history of psychiatric diagnosis (5.2%) was significantly lower than general population estimates (14.0%; p < .001), and this effect was consistent across sexes and age groups. SCAT3 cognitive and balance performance did not differ based on baseline symptom reporting.Conclusions: Healthy adolescent student athletes frequently report concussion-like symptoms at baseline. Clinicians should factor pre-injury symptomatology and medical history into concussion management when determining symptom etiology throughout the course of recovery.

Prevalence and proposed mechanisms of chronic low back pain in baseball: part i.

ABSTRACT The prevalence of low back pain (LBP) among active baseball players ranges between 3 and 15%. The execution of baseball-specific manoeuvres, such as pitching or batting, may be related to the onset of LBP. These baseball motions are complex and require appropriate activation of the core musculature to produce a well-timed motion with forces minimized at the extremities. The spine, core and back musculature are involved with acceleration and deceleration of rotational motions. This narrative review synopsizes the available evidence of the prevalence of and mechanical factors underlying LBP in the baseball population. Possible mechanical mechanisms linking baseball play to LBP include aberrant motion, improper timing, high lumbar stress due to mechanical loading and lumbopelvic strength deficits. Potential clinical implications relating to these possible mechanical mechanisms will also be highlighted. The state of the evidence suggests that there are deficits in understanding the role of baseball motion and playing history in the development of spine conditions.

Occipital neuralgia as a sequela of sports concussion: a case series and review of the literature.

Sports and recreation-related concussions are common, with an annual incidence in the United States estimated to be between 1.6 and 3.8 million (19,20,22). The majority of these injuries are considered to be self-limited; however prolonged symptoms of greater than 3 months are not uncommon (5,10,25,27). In particular, delayed headache is associated with delayed recovery from concussion and increased risk of postconcussion syndrome (3,8,10). The pathophysiology of postconcussive headache is likely complex and multifactorial, involving both local injury as well as the activation of peripheral and central pain pathways. Occipital neuralgia (ON) is a known etiology of headaches and may stem from trauma to the neck, such as with a concussion or whiplash injury (23). ON also may feature symptoms such as nausea, dizziness, and photosensitivity that are associated commonly with concussion. Despite these features, ON may be an underappreciated cause of headache in sports-related concussion; a PubMed search returned only one reference when using the terms “sports” and “occipital neuralgia” (26). Due to the prominence of headache as a symptom in concussion, the potential for concomitant conditions such as ON arising from the same traumatic injury, and the overlapping symptomatology between these conditions, it is important that clinicians be able to recognize ON in the management of concussion. In this case series, we will report on our observation of ON as a significant factor in the postconcussion headaches and symptomatology of three patients. We also will present a brief review of the available literature on ON, with attention to its relevant anatomy, presentation, examination, and treatment.

Recurrence and return to play after shoulder instability events in young and adolescent athletes: a systematic review and meta-analysis

Background Shoulder instability in athletics is a common occurrence. However, there is controversy as to whether non-operative versus operative management is the most effective treatment in youth athletes. We systematically reviewed recurrence and return to play (RTP) after shoulder instability events in youth athletes based on surgical versus non-surgical intervention. Design The systematic review concerned studies published before August 2016. Statistical analysis was performed to compare rates of recurrence for each extracted risk factor. Pooled ORs were analysed using random-effects meta-analysis. Results 17 studies comprising 654 total shoulder instability events met the criteria for inclusion (438 men and 158 women; 507 cases traumatic and 20 atraumatic). Patients were grouped by whether they received non-operative or operative treatment. The primary non-operative group was more likely to have recurrence compared to the primary operative group (OR=13.41; 99% CI 3.60 to 49.93, p<0.001). Patients <14 years old in the primary non-operative group were less likely to recur compared to those aged ≥14 years (OR=0.16; 99% CI 0.06 to 0.43, p<0.001). The rate of recurrence in patients aged <14 years was high (44.44%). For RTP, there is evidence that RTP rates were higher for primary operative patients (95.3%) versus primary non-operative (41.3%, Z=6.12, p<0.001) and secondary operative patients (77.6%, Z=2.66, p=0.008). Conclusions This meta-analysis summarises a mix of 17 acceptable quality level II and III prospective and retrospective cohort studies. Given the superior rates of recurrence and RTP, primary operative treatment for shoulder instability should be considered in youth athletes aged ≥14 years. Additionally, the recurrence rate in athletes aged <14 years is significant.

Assessment and rehabilitation of chronic low back pain in baseball: part II

ABSTRACT Repetitive throwing and hitting motions in baseball place mechanical stresses to the lumbar spine which may cause low back pain (LBP). Pain may be due to vertebral stress reactions or insufficiency fractures, intervertebral disc degeneration or intervertebral disc herniation. Untreated chronic conditions have high potential to lead to a more significant injury such as spondylolysis. Chronic LBP increases the risk for missed playing time, early career termination and lower quality of life after retirement. Proper clinical assessment and prevention/rehabilitation of LBP in this population is thus important for performance, play time and overall long-term quality of life. This narrative review synopsizes the available evidence for assessment and rehabilitation of baseball players with LBP, including the structured rehabilitative techniques and programmes which should be administered to affected players. The state of the evidence suggests that there are deficits in identifying the optimal prevention and rehabilitation prescription components for the variety of LBP-inducing injuries in this athletic population.

Mechanisms and Treatments for Shoulder Injuries in Overhead Throwing Athletes.

Shoulder injuries in overhead throwing athletes are very common. Throwing volume and mechanical forces that are placed on the glenohumeral joint and associated soft tissue structures are contributors. Poor biomechanics and weak links in the kinetic chain place this athletic population at increased risk for shoulder injuries. Common biomechanical deficiencies in overhead throwing athletes typically involve poor sequential timing of muscle activity and insufficient coordination also presented in shoulder elevation and other functional tasks. Kinetic chain deficits will lead to injury due to poor transference of energy from the lower extremities to the dominant upper extremity. Correction of these deficits involves effective treatment and prevention strategies. These include core and hip strengthening, balance training, optimize timing of biomechanical phases and events for each throwing movement, and following recommended rest guidelines. This article will synopsize current evidence of sport-specific injury mechanisms, injury treatment, and prevention of the shoulder in overhead throwing athletes.

An Occult Presentation of Appendicitis in a Patient with Tetraplegia

Zaremski JL, Jayawardena V, Lew HL: An occult presentation of appendicitis in a patient with tetraplegia.A 26-yr-old man with a C4 American Spinal Injury Association impairment scale B spinal cord injury was admitted due to a left calf pressure ulcer. The patients initial laboratory results and physical examination findings were unremarkable, except for a stage IV pressure ulcer. On day 7, the patient developed fever and leukocytosis. A complete culture workup performed did not yield abnormalities. A computed tomography scan of the abdomen and pelvis revealed retrocecal appendicitis with a retrocecal abscess containing an appendicolith. The abscess was drained percutaneously, and the patient was given a 6-wk course of intravenous antibiotics. The patient returned to the hospital 30 days later for an appendectomy. Typical signs of appendicitis can be masked in patients with a spinal cord injury. It is crucial to include appendicitis in the differential diagnosis of this population, even though the presentation is as nonspecific as fever and leukocytosis.