Mitchell K. Freedman

Femoral, Saphenous Nerve Palsy After Tourniquet Use: A Case Report

Persistent motor and sensory abnormalities after surgery may affect the rehabilitation process. Patients with continued weakness may be perceived as lacking motivation by health care providers. However, there may be an underlying pathophysiologic abnormality preventing patients from progressing through their rehabilitation programs. We report a case of a 20-year-old man who underwent surgical repair of multiple knee structures with the use of a pneumatic tourniquet. Several weeks after surgery, electromyographic evaluation was done because he was having difficulty in his rehabilitation because of persistent weakness. An electromyography and nerve conduction study (NCS) revealed femoral and saphenous nerve palsies. Our report is the first on tourniquet-induced saphenous nerve injury as well as on abnormal femoral NCSs caused by tourniquet use. A review of the literature indicates that tourniquet-induced nerve palsies are not a rare event. Further evaluation should be considered if patients who are having persistent weakness or sensory findings after surgery have used a tourniquet.

Interventions in Chronic Pain Management. 5. Approaches to Medication and Lifestyle in Chronic Pain Syndromes

UNLABELLED This self-directed learning module first reviews the importance of weight management and smoking cessation in the treatment of axial low back pain and then describes the use of medication in complex regional pain syndrome and trigeminal neuralgia. It is part of the chapter on chronic pain in the Self-Directed Physiatric Education Program for practitioners in physical medicine and rehabilitation. The first objective explores the correlation of tobacco usage and obesity with lower back pain. The second objective reviews the option for medication management in patients with complex regional pain syndromes. The third objective examines the management of trigeminal neuralgia in a patient with multiple sclerosis. OVERALL ARTICLE OBJECTIVE To discuss the importance of addressing obesity and smoking cessation in patients with low back pain and medication usage in trigeminal neuralgia and complex regional pain syndromes.

Common peroneal entrapment neuropathy secondary to a popliteal lipoma: ultrasound superior to magnetic resonance imaging for diagnosis.

This report demonstrates the utility of musculoskeletal ultrasound (US) in the evaluation of a soft-tissue mass compressing the peroneal nerve when both magnetic resonance imaging (MRI) and electrodiagnostic studies were inconclusive. We describe the case of a woman who presented with pain and weakness in the distribution of the common peroneal nerve (CPN). Electrodiagnostic studies and MRI of the knee were normal, but US revealed her pathology to be a mobile lipoma in the popliteal fossa that compressed the CPN at its bifurcation into the deep peroneal nerve (DPN) and superficial peroneal nerve (SPN) with leg extension. Once the lipoma was located, appropriate surgical exploration and excision resulted in complete resolution of symptoms.

Update on the Role of Z-Joint Injection and Radiofrequency Neurotomy for Cervicogenic Headache

Cervicogenic headache is a common secondary headache that typically is referred from the upper cervical spine, that is, segments C3‐C4 and rostral. Diagnostic injections to one or more of these segmental joints (including the atlanto‐occipital joint, atlanto‐axial joint, and C2‐C3 and C3‐C4 zygapophysial joints [z‐joints]) frequently are used to establish the pain generator in the cervical spine that is responsible for the radiation of pain into the head. Therapeutic interventions used to alleviate pain include corticosteroid injections into the z‐joint (ie, C2‐C3 and C3‐C4) or bony articulations (ie, C0‐C1 and C2‐C2), and percutaneous radiofrequency (RF) neurotomy at the C2‐C3 and C3‐C4 z‐joints. RF neurotomy may provide the most sustained relief of headache symptoms although the relief typically is not permanent. Pulsed RF, a nondestructive modality, may also have benefit for cervicogenic headaches.

Interventions in Chronic Pain Management. 6. Interventional Approaches to Chronic Pain Management

UNLABELLED This self-directed learning module highlights strategies for interventional treatments for chronic pain disorders. It is part of the chapter on chronic pain in the Self-Directed Physiatric Education Program for practitioners in physical medicine and rehabilitation. Specifically, the first module reviews an interventional protocol for recalcitrant buttock and hip pain. The protocol includes hip and spinal injections, neuroablative lesioning, and percutaneous epidural neuroplasty. The second module reviews implantable treatments (spinal cord stimulation, implantable pumps) for intractable pain. OVERALL ARTICLE OBJECTIVE To discuss interventional pain management approaches in the treatment of chronic pain disorders.

Interventions in chronic pain management. 2. Diagnosis of cervical and thoracic pain syndromes.

UNLABELLED This self-directed learning module highlights approaches to the investigation of common cervical and thoracic conditions. It is part of the chapter on chronic pain management in the Self-Directed Physiatric Education Program for practitioners in physical medicine and rehabilitation. The differential diagnosis of cervical and thoracic syndromes as well as cervicogenic headache is reviewed. The need for a comprehensive history and physical examination is emphasized. Indications for diagnostic tests including magnetic resonance imaging, computed tomography scan, bone scan, diskography, radiographs, diagnostic injections, and electrodiagnostic studies are discussed with the idea that testing should be performed and interpreted with the specific clinical presentation in mind. OVERALL ARTICLE OBJECTIVE To discuss the differential diagnoses for and investigation of common cervical and thoracic conditions and cervicogenic headache.

Electrodiagnostic Evaluation of Compressive Nerve Injuries of the Upper Extremities

Electrodiagnostic testing includes electromyography and nerve conduction studies that are physiologic tests used in the diagnosis of peripheral nerve injuries. It is a supplement rather than a replacement for a physical examination. This article reviews the terminology as well as the findings seen and used in electrodiagnostic studies. Common compression nerve injuries including the median, ulnar, radial, axillary, and suprascapular nerves and their electrical findings are reviewed.

Interventions in Chronic Pain Management. 1. Update on Important Definitions in Pain Management

UNLABELLED This self-directed learning module highlights definitions used in pain management. It is part of the chapter on chronic pain management in the Self-Directed Physiatric Education Program for practitioners in physical medicine and rehabilitation. Terms that describe pain and narcotic use that are frequently used and misused are reviewed. Complex regional pain syndrome criteria are presented. Mechanisms, criteria, and potential problems for practitioners to become certified in various areas of pain management are discussed. OVERALL ARTICLE OBJECTIVE To define common terminology used in pain management, complex regional pain syndrome, and the criteria for pain management certification.

Interventions in Chronic Pain Management. 3. Evaluation and Management of Lumbar Pain Syndromes

UNLABELLED This self-directed learning module highlights approaches to the investigation of selected lumbar spine conditions. It is part of the chapter on chronic pain management in the Self-Directed Physiatric Education Program for practitioners in physical medicine and rehabilitation. The first objective explores the diagnostic evaluation for groin and buttock pain in a 66-year-old man with pain during ambulation. The second objective describes the unique challenges of managing the adolescent with low back pain. OVERALL ARTICLE OBJECTIVE To review evaluation and management strategies for selected lumbar pain syndromes.

Patient-Reported Disability Measures Do Not Correlate with Electrodiagnostic Severity in Carpal Tunnel Syndrome.

Background: Electrophysiologic studies including electromyography and nerve conduction studies play a role in the evaluation of carpal tunnel syndrome (CTS), despite evidence that these studies do not correlate with CTS-specific symptom scores. There is a lack of evidence comparing electrophysiologic data with general measures of function. Methods: Fifty patients presenting for CTS treatment over an 8-month period were analyzed retrospectively. All patients completed surveys including the Quick Disabilities of the Arm, Shoulder, and Hand questionnaire (DASH) and the Medical Outcomes Study 12-Item Short-Form Survey [(physical component summary 12, mental component summary (MCS-12)]. Electromyography and nerve conduction studies were performed on all patients and compared with outcome scores. Results: Analysis demonstrated no relationship between DASH or MCS-12 and electrodiagnostic severity. No significant correlations were noted between DASH or MCS-12 and median motor or sensory latency. There was a moderate–weak correlation (rho = 0.34) between more severe electrophysiologic grade and better function based on physical component summary 12. Conclusions: Electrodiagnostic severity grades do not correlate with patient-reported disability, including the DASH and MCS–12 surveys. There is a counterintuitive correlation between more-severe electrodiagnostic findings and decreased physical disability. These findings indicate that disability may not correlate with electrodiagnostic severity of median neuropathy in CTS.