Jeffrey S. Brault

Ultrasound elastography: the new frontier in direct measurement of muscle stiffness.

The use of brightness-mode ultrasound and Doppler ultrasound in physical medicine and rehabilitation has increased dramatically. The continuing evolution of ultrasound technology has also produced ultrasound elastography, a cutting-edge technology that can directly measure the mechanical properties of tissue, including muscle stiffness. Its real-time and direct measurements of muscle stiffness can aid the diagnosis and rehabilitation of acute musculoskeletal injuries and chronic myofascial pain. It can also help monitor outcomes of interventions affecting muscle in neuromuscular and musculoskeletal diseases, and it can better inform the functional prognosis. This technology has implications for even broader use of ultrasound in physical medicine and rehabilitation practice, but more knowledge about its uses and limitations is essential to its appropriate clinical implementation. In this review, we describe different ultrasound elastography techniques for studying muscle stiffness, including strain elastography, acoustic radiation force impulse imaging, and shear-wave elastography. We discuss the basic principles of these techniques, including the strengths and limitations of their measurement capabilities. We review the current muscle research, discuss physiatric clinical applications of these techniques, and note directions for future research.

Partial lumbosacral transitional vertebra resection for contralateral facetogenic pain

Study Design. Case report of surgically treated mechanical low back pain from the facet joint contralateral to a unilateral anomalous lumbosacral articulation (Bertolotti’s syndrome). Objectives. To describe the clinical presentation, diagnostic evaluation, and management of facet-related low back pain in a 17-year-old cheerleader and its successful surgical treatment with resection of a contralateral anomalous articulation. Summary of Background Data. Lumbosacral transitional vertebrae are common in the general population. Bertolotti’s syndrome is mechanical low back pain associated with these transitional segments. Little is known about the pathophysiology and mechanics of these vertebral segments and their propensity to be pain generators. Treatment of this syndrome is controversial, and surgical intervention has been infrequently reported. Method. A retrospective chart analysis and radiographic review were performed. Results. Repeated fluoroscopically guided injections implicated a symptomatic L6–S1 facet joint contralateral to an anomalous lumbosacral articulation. Eventually, a successful surgical outcome was achieved with resection of the anomalous articulation. Conclusion. Clinicians should consider the possibility that mechanical low back pain may occur from a facet contralateral to a unilateral anomalous lumbosacral articulation, even in a young patient. Although reports of surgical treatment of Bertolotti’s syndrome are infrequent, resection of the anomalous articulation provided excellent results in this patient, presumably because of reduced stresses on the symptomatic facet.

Evidence-informed management of chronic low back pain with traction therapy

The management of chronic low back pain (CLBP) has proven to be very challenging in North America, as evidenced by its mounting socioeconomic burden. Choosing among available nonsurgical therapies can be overwhelming for many stakeholders, including patients, health providers, policy makers, and third-party payers. Although all parties share a common goal and wish to use limited health-care resources to support interventions most likely to result in clinically meaningful improvements, there is often uncertainty about the most appropriate intervention for a particular patient. To help understand and evaluate the various commonly used nonsurgical approaches to CLBP, the North American Spine Society has sponsored this special focus issue of The Spine Journal, titled Evidence-Informed Management of Chronic Low Back Pain Without Surgery. Articles in this special focus issue were contributed by leading spine practitioners and researchers, who were invited to summarize the best available evidence for a particular intervention and encouraged to make this information accessible to nonexperts. Each of the articles contains five sections (description, theory, evidence of efficacy, harms, and summary) with common subheadings to facilitate comparison across the 24 different interventions profiled in this special focus issue, blending narrative and systematic review methodology as deemed appropriate by the authors. It is hoped that articles in this special focus issue will be informative and aid in decision making for the many stakeholders evaluating nonsurgical interventions for CLBP.

Accuracy of Sonographically Guided and Palpation Guided Scaphotrapeziotrapezoid Joint Injections

The purpose of this study was to determine and compare the accuracies of sonographically guided and palpation guided scaphotrapeziotrapezoid (STT) joint injections in a cadaveric model.

An unusual presentation of acute calcific tendinitis in the hand.

Acute calcific tendinitis (ACT) is a relatively uncommon disorder of the hand and wrist. ACT is a well-known condition of the shoulder, but it often goes unrecognized when occurring in the hand or wrist. The overall lack of familiarity along with the non-specific symptoms associated with ACT frequently leads to misdiagnosis or delay in diagnosis. We report a case of acute calcific tendinitis occurring in the carpal tunnel which is a rare presentation.

Digital ischemia after carpal tunnel injection: a case report.

A 51-year-old woman described paresthesias in her right thumb, index, and middle fingers consistent with carpal tunnel syndrome. Using a sterile technique, a 25-G, 1 1/4-in needle was introduced ulnar to the palmaris longus tendon, and a mixture of 1.5 mL of 40 mg/mL of triamcinolone acetonide and 1.5 mL of 1% lidocaine was injected. After the injection, the patients hand exhibited signs of ischemia including coolness and discoloration. Rewarming of the hand with paraffin was performed immediately, and normative color returned. At follow-up visits, the patient described burning in the hand, and blotchiness of the digits was noted. A magnetic resonance imaging angiogram of the right wrist showed a single deep palmar arch. Electromyography and nerve conduction study weeks after the injection showed bilateral median neuropathies, moderately severe on the right and mild on the left. She underwent an open carpal tunnel release 6 weeks postinjection. The patient did well and returned to her job without restrictions. The exact etiology of the hand ischemia is unclear but may be related to vasospasm as has been described in the spine-injection literature. Regardless of the etiology, this case shows an uncommon adverse event in a commonly performed procedure and raises questions for further review.

Ultrasound-guided thoracic facet injections: description of a technique.

The purpose of this study was to describe a technique using ultrasound guidance to perform thoracic facet joint injections.

Lumbar Transforaminal Epidural Steroid Injections: Does Immediate Post‐Procedure Pain Response Predict Longer Term Effectiveness?

OBJECTIVE To assess whether the immediate anesthetic response of pain relief (sensory blockade) or weakness (motor blockade) after lumbar transforaminal epidural steroid injection (TFESI) is associated with longer term effectiveness in pain relief and functional recovery. DESIGN Retrospective observational study. SETTING Single academic radiology practice. SUBJECTS Three thousand six hundred forty-five lumbar TFESIs performed on 2,634 subjects. METHODS Subjects completed a pain numerical rating scale (NRS, 0-10) and Roland-Morris disability questionnaire (R-M) prior to and immediately after TFESI (NRS) and at 2 weeks and 2 months follow-up. Successful pain relief was ≥50% NRS reduction; functional success was ≥40% R-M reduction. Post-procedure motor weakness was recorded. Logistic regression models assessed association of immediate post-procedure NRS response, and NRS or R-M response at 2 weeks, with successful outcomes at 2 months. C-index assessed model discrimination; values closer to 1.0 indicated better discrimination. RESULTS Immediate NRS response was weakly associated with 2-month outcomes (C-index = 0.58). NRS and R-M responses at 2 weeks were more strongly associated with the 2-month response (C-indices 0.77, 0.80, respectively). Post-procedure motor blockade had little association with successful 2-month NRS or R-M outcomes (C-indices 0.51, 0.50, respectively). Patients that responded at 2 weeks were more likely to be responders at 2 months than those who were non-responders at 2 weeks (odds ratio = 6.49, confidence interval 5.38, 7.84). CONCLUSION Immediate post-TFESI pain relief does not strongly predict longer term effectiveness in pain relief or functional recovery. Response in pain relief or functional recovery at 2 weeks is more strongly associated with 2-month outcomes.

Ultrasound-Assisted Percutaneous Needle Fasciotomy for Dupuytren's Contracture.

Although percutaneous needle fasciotomy for Dupuytrens contracture is a simple, inexpensive procedure, it is a blind procedure with risks including injury to nerves, arteries, and tendons. The authors describe a novel technique using ultrasound as an adjunct to percutaneous fasciotomy for Dupuytrens contracture. Generally, patients have no postoperative restrictions other than to avoid submerging their hands for 48 hours. To date, the authors have noted, in 66 cases, no permanent complete nerve dysfunction following needle aponeurotomy using ultrasound assistance. Recurrence of the disease is the most common complication, occurring at a higher rate than with open procedures. Ultrasound mapping of the digital neurovascular structures can be successfully used as an adjunct to help prevent these neurovascular complications.

Botox and Thumb MCP Radial Collateral Ligament Reconstruction

Background  We report the use of botulinum toxin to aid in the treatment of chronic radial collateral ligament insufficiency of the thumb. Case Description  Treatment included autograft tendon reconstruction and cast immobilization. Six weeks postoperatively, prior to hand therapy, the patient underwent an ultrasound-guided botulinum neurotoxin A injection into the adductor pollicis muscle to negate its deforming forces on the reconstruction. The patient made an excellent recovery and 1 year postoperatively was pain free and had a stable radial collateral ligament (RCL) upon examination. Literature Review  The outcomes of RCL repair and reconstruction are unpredictable, in part, due to the strong opposing forces of the adductor pollicis. Clinical Relevance  The use of Botox injection may enhance the outcomes of RCL repair or reconstruction by neutralizing the deforming forces of the adductor muscle.