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Oliveira J, Bem G, Agrelo A. Ganglion impar block in chronic cancer-related pain - A review of the current literature. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2024:S2341-1929(24)00081-7. [PMID: 38670492 DOI: 10.1016/j.redare.2024.04.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Revised: 07/16/2023] [Accepted: 01/26/2024] [Indexed: 04/28/2024]
Abstract
Oncologic chronic pain is often difficult to control, especially in anatomical areas with multiple and complex innervation, such as the pelvic/perineal region. The ganglion impar block (GIB) is a procedure with growing interest and varied applicability. It has been used in several benign and malignant causes of pelvic and perineal pain refractory to pharmacological treatment. We conducted a review of all articles published in PUBMED® until the 30th of October 2022 regarding GIB in oncologic pain. 19 articles were identified with a total of 278 patients. Both chronic cancer pain and chronic postcancer treatment pain patients were included. We reviewed the various techniques, approaches, and therapeutic options that were employed. No serious adverse effects were reported. GIB appears to be an effective and safe procedure that should be considered in patients with intractable perineal cancer-related pain.
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Affiliation(s)
- J Oliveira
- Anesthesiology and Critical Care Department, Instituto Português de Oncologia do Porto Francisco Gentil, Porto, Portugal.
| | - G Bem
- Anesthesiology and Critical Care Department, Instituto Português de Oncologia do Porto Francisco Gentil, Porto, Portugal
| | - A Agrelo
- Anesthesiology and Critical Care Department, Instituto Português de Oncologia do Porto Francisco Gentil, Porto, Portugal; Pain Unit, Anesthesiology and Critical Care Department, Instituto Português de Oncologia do Porto Francisco Gentil, Porto, Portugal
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Rocha-Romero A, Plancarte-Sánchez R, Juarez AM, Hernández-Porras BC. Ganglion impar block a matter of safety and efficacy. Reg Anesth Pain Med 2023; 48:234-235. [PMID: 36526304 DOI: 10.1136/rapm-2022-104062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2022] [Accepted: 10/03/2022] [Indexed: 12/23/2022]
Affiliation(s)
- Andrés Rocha-Romero
- Anesthesia and Pain Management, Centro Nacional de Rehabilitación, Hospital del Trauma, San Jose, Costa Rica
| | | | - Angel M Juarez
- Pain Clinic, Instituto Nacional de Cancerología, Ciudad de Mexico, Mexico
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Feigin G, Wang NN, Di Grazia V, Peng P. Novel approach for pericapsular radiofrequency ablation of sacrococcygeal junction for patients with coccydynia. Reg Anesth Pain Med 2022; 47:259-262. [DOI: 10.1136/rapm-2021-103183] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Accepted: 12/05/2021] [Indexed: 11/04/2022]
Abstract
IntroductionCoccydynia is a multifactorial complex clinical challenge. A multimodal approach with both conservative measures and procedural interventions is often recommended. We described a novel approach of radiofrequency (RF) ablation for the management of coccydynia.MethodsThree patients with known history of coccydynia refractory to conservative therapy were referred to our clinic. All received different types of RF ablation before: one with anterior bipolar lesion with no analgesia benefit, one with posterior stripped lesion with good benefit but only after 8 weeks of pain flare and one received anterior monopolar lesion with 50% pain reduction for 2–3 months. All subjects underwent a novel RF ablation to the anterior surface of the sacrococcygeal and intercoccygeal joints with two bipolar lesions using multi-tined needles under fluoroscopy guidance. One bipolar lesion was between two needles: one in the sacrococcygeal and another in the intercoccygeal (between first and second coccyx) joints. Another bipolar lesion was between needles on both side of the sacrococcygeal joint.ResultsAll experienced at least 65% pain relief for 6 months. The sitting endurance increased from less than 5 min to an average of 70 min. No adverse effect was observed in two and in the patient who used to have pain flare after lesioning, the pain flare lasted only for 2 weeks.DiscussionThe configuration of the two bipolar lesions with multi-tined needles in this case series stimulates the thinking of new approach for the ablation technique for pain from coccyx. Further prospective large case cohort study is needed.
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Aman MM, Mahmoud A, Deer T, Sayed D, Hagedorn JM, Brogan SE, Singh V, Gulati A, Strand N, Weisbein J, Goree JH, Xing F, Valimahomed A, Pak DJ, El Helou A, Ghosh P, Shah K, Patel V, Escobar A, Schmidt K, Shah J, Varshney V, Rosenberg W, Narang S. The American Society of Pain and Neuroscience (ASPN) Best Practices and Guidelines for the Interventional Management of Cancer-Associated Pain. J Pain Res 2021; 14:2139-2164. [PMID: 34295184 PMCID: PMC8292624 DOI: 10.2147/jpr.s315585] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Accepted: 06/18/2021] [Indexed: 12/17/2022] Open
Abstract
Moderate to severe pain occurs in many cancer patients during their clinical course and may stem from the primary pathology, metastasis, or as treatment side effects. Uncontrolled pain using conservative medical therapy can often lead to patient distress, loss of productivity, shorter life expectancy, longer hospital stays, and increase in healthcare utilization. Various publications shed light on strategies for conservative medical management for cancer pain and a few international publications have reviewed limited interventional data. Our multi-institutional working group was assembled to review and highlight the body of evidence that exists for opioid utilization for cancer pain, adjunct medication such as ketamine and methadone and interventional therapies. We discuss neurolysis via injections, neuromodulation including targeted drug delivery and spinal cord stimulation, vertebral tumor ablation and augmentation, radiotherapy and surgical techniques. In the United States, there is a significant variance in the interventional treatment of cancer pain based on fellowship training. As a first of its kind, this best practices and interventional guideline will offer evidenced-based recommendations for reducing pain and suffering associated with malignancy.
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Affiliation(s)
- Mansoor M Aman
- Department of Anesthesiology, Division of Pain Medicine, Advocate Aurora Health, Oshkosh, WI, USA
| | - Ammar Mahmoud
- Department of Anesthesiology, Division of Pain Medicine, Northern Light Health Eastern Maine Medical Center, Bangor, ME, USA
| | - Timothy Deer
- The Spine and Nerve Center of the Virginias, Charleston, WV, USA
| | - Dawood Sayed
- Department of Anesthesiology, Pain and Perioperative Medicine, University of Kansas Medical Center, Kansas City, KS, USA
| | - Jonathan M Hagedorn
- Department of Anesthesiology and Perioperative Medicine, Division of Pain Medicine, Mayo Clinic, Rochester, MN, USA
| | - Shane E Brogan
- Department of Anesthesiology, Division of Pain Medicine, University of Utah, Salt Lake City, UT, USA
| | - Vinita Singh
- Department of Anesthesiology, Division of Pain Medicine, Emory University, Atlanta, GA, USA
| | - Amitabh Gulati
- Department of Anesthesiology and Critical Care, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Natalie Strand
- Department of Anesthesiology, Division of Pain Medicine, Mayo Clinic, Phoenix, AZ, USA
| | - Jacqueline Weisbein
- Department of Anesthesiology, Chronic Pain Division, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Johnathan H Goree
- Interventional Pain Medicine, Napa Valley Orthopedic Medical Group, Napa, CA, USA
| | - Fangfang Xing
- Swedish Pain Services, Swedish Health Services, Seattle, WA, USA
| | - Ali Valimahomed
- Gramercy Pain Center, Holmdel, NJ, & Advanced Orthopedics Sports Medicine Institute, Freehold, NJ, USA
| | - Daniel J Pak
- Department of Anesthesiology, Division of Pain Medicine, New York-Presbyterian Hospital/Weill Cornell Medical College, New York, NY, USA
| | - Antonios El Helou
- Department of Neurosciences, Division of Neurosurgery, The Moncton Hospital, Moncton, NB. Assistant Professor, Department of Surgery, Dalhousie University, Halifax, NS, Canada
| | | | - Krishna Shah
- Assistant Professor of Anesthesiology, Baylor St. Luke’s Medical Center, Baylor College of Medicine, Houston, TX, USA
| | - Vishal Patel
- Department of Anesthesiology, Division of Pain Medicine, Advocate Aurora Health, Oshkosh, WI, USA
| | - Alexander Escobar
- Department of Anesthesiology and Pain Medicine, University of Toledo Medical Center, Toledo, OH, USA
| | - Keith Schmidt
- AMITA Neurosciences Institute, Comprehensive Pain Management Program, St. Alexius Medical Center, Hoffman Estates, IL, USA
| | - Jay Shah
- SamWell Institute for Pain Management, Colonia, NJ, USA
| | - Vishal Varshney
- Department of Anesthesia, Providence Healthcare, Vancouver, BC, Canada & Department of Anesthesiology, Pharmacology, Therapeutics, University of British Columbia, Vancouver, BC, Canada
| | - William Rosenberg
- Center for the Relief of Pain, Midwest Neurosurgery Associates, Kansas City, Missouri, USA
| | - Sanjeet Narang
- Department of Anesthesiology, Pain and Perioperative Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
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Kuek DKC, Chung SL, Zishan US, Papanikitas J, Yanny S, Meagher T, Teh J, Hughes R, Liong WC, McKean D. Conus infarction after non-guided transcoccygeal ganglion impar block using particulate steroid for chronic coccydynia. Spinal Cord Ser Cases 2019; 5:92. [PMID: 31700690 PMCID: PMC6831570 DOI: 10.1038/s41394-019-0237-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2019] [Revised: 10/23/2019] [Accepted: 10/25/2019] [Indexed: 12/19/2022] Open
Abstract
Introduction Ganglion impar block (GIB) is a well-recognised treatment for chronic coccydynia. Several side effects have previously been described with this procedure, including transient motor dysfunction, bowel, bladder, and sexual dysfunction, neuritis, rectal perforation, impingement of the sciatic nerve, cauda equina syndrome, and infection. Case presentation We describe the first report of imaging-documented conus infarction after an unguided-GIB performed in theatre using particulate steroids for a 17-year-old patient with coccydynia. Immediately post-GIB, patient developed transient neurological deficits in her lower limbs of inability to mobilise her legs that lasted for 24 h. These include back and leg pain, decreased power and movement, increased tone, brisk reflexes, reduced light touch sensation and proprioception of legs up to the T10 level. Urgent MRI spine showed intramedullary hyperintense signal within the conus and mild restricted diffusion on the distal cord and conus, suggestive of an acute conus infarction. On follow-up, the GIB did not result in symptom improvement of coccydynia and there was persistent altered sensation of her legs. Discussion Various approaches of ganglion impar block have been described and performed in the past with different imaging techniques and injectants. A few cases of unusual neurological complications have been reported with the use of epidural steroid injections and ganglion impar block. Clinicians should be aware of the possible neurological complications following ganglion impar blocks and the risk of inadvertent intravascular injection of particulate steroids can potentially to be minimised by using imaging guidance.
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Affiliation(s)
| | - Siok Li Chung
- Stoke Mandeville Hospital, Buckinghamshire Healthcare NHS Trust, Aylesbury, UK
| | | | - Joseph Papanikitas
- Stoke Mandeville Hospital, Buckinghamshire Healthcare NHS Trust, Aylesbury, UK
| | - Sarah Yanny
- Stoke Mandeville Hospital, Buckinghamshire Healthcare NHS Trust, Aylesbury, UK
| | - Tom Meagher
- Stoke Mandeville Hospital, Buckinghamshire Healthcare NHS Trust, Aylesbury, UK
| | - James Teh
- Nuffield Orthopaedic Centre, Oxford University Hospitals NHS Trust, Oxford, UK
| | - Richard Hughes
- Stoke Mandeville Hospital, Buckinghamshire Healthcare NHS Trust, Aylesbury, UK
| | - Wei Chuen Liong
- Stoke Mandeville Hospital, Buckinghamshire Healthcare NHS Trust, Aylesbury, UK
| | - David McKean
- Stoke Mandeville Hospital, Buckinghamshire Healthcare NHS Trust, Aylesbury, UK
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Evidence Analysis of Sympathetic Blocks for Visceral Pain. CURRENT PHYSICAL MEDICINE AND REHABILITATION REPORTS 2019. [DOI: 10.1007/s40141-019-00226-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Sencan S, Cuce I, Karabiyik O, Demir FU, Ercalik T, Gunduz OH. The influence of coccygeal dynamic patterns on ganglion impar block treatment results in chronic coccygodynia. Interv Neuroradiol 2018; 24:580-585. [PMID: 29969959 DOI: 10.1177/1591019918781673] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Objective Ganglion impar block (GIB) can be performed in patients with chronic coccygodynia who do not respond to conservative treatments. We investigated the effect of coccygeal dynamic patterns on the treatment outcome in patients with chronic coccygodynia treated with GIB. Materials and methods We retrospectively analyzed the data for patients diagnosed with chronic coccygodynia who underwent GIB only once by a transsacrococcygeal method under fluoroscopy guidance in our Pain Medicine Clinic. Patients were assessed with standard and dynamic coccyx radiographs and classified according to coccygeal mobility. Pain scores were assessed with a numerical rating scale (NRS) before and after the intervention (at 1 hour and 4, 12 and 24 weeks). A 50% or more reduction in the NRS score was accepted as significant pain relief. Results Of the 37 patients included in the study, 14 had normal coccyx (Group I) and 23 had immobile coccyx (Group II) based on the radiological evaluation. The NRS scores were significantly reduced in both groups on each follow-up visit but there was no significant difference between the two groups in terms of pre- and post-intervention NRS scores. Significant pain relief was achieved in 42.9% and 61.9% of patients in Group I and II at the last examination, respectively. Conclusion GIB administered by transsacrococcygeal method in patients with chronic coccygodynia is a safe and alternative treatment approach with reduced pain scores and low complication rates. In patients with chronic coccygodynia, having a normal or immobile coccyx does not appear to affect treatment outcomes.
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Affiliation(s)
- Savas Sencan
- 1 Department of Physical Medicine and Rehabilitation, Division of Pain Medicine, Marmara University Pendik Training and Research Hospital, Istanbul, Turkey
| | - Isa Cuce
- 2 Department of Physical Medicine and Rehabilitation, Adiyaman University Training and Research Hospital, Adiyaman, Turkey
| | - Ozgur Karabiyik
- 3 Department of Radiology, Kayseri Training and Research Hospital, Kayseri, Turkey
| | - Fatmagul U Demir
- 4 Department of Physical Medicine and Rehabilitation, Kayseri Training and Research Hospital, Kayseri, Turkey
| | - Tulay Ercalik
- 5 Department of Physical Medicine and Rehabilitation, Division of Pain Medicine, Sisli Hamidiye Etfal Training and Research Hospital, Istanbul, Turkey
| | - Osman H Gunduz
- 6 Department of Physical Medicine and Rehabilitation, Division of Pain Medicine, Faculty of Medicine, Marmara University, Istanbul, Turkey
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Abstract
The inputs from sympathetic ganglia have been known to be involved in the pathophysiology of various painful conditions such as complex regional pain syndrome, cancer pain of different origin, and coccygodynia. Sympathetic ganglia blocks are used to relieve patients who suffer from these conditions for over a century. Many numbers of local anesthetics such as bupivacaine or neurolytic agents such as alcohol can be chosen for a successful block. The agent is selected according to its duration of effect and the purpose of the injection. Most commonly used sympathetic blocks are stellate ganglion block, lumbar sympathetic block, celiac plexus block, superior hypogastric block, and ganglion Impar block. In this review, indications, methods, effectiveness, and complications of these blocks are discussed based on the data from the current literature.
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Affiliation(s)
- Osman Hakan Gunduz
- Department of Physical Medicine and Rehabilitation, Faculty of Medicine, Marmara University, Istanbul, Turkey
| | - Ozge Kenis-Coskun
- Department of Physical Medicine and Rehabilitation, Faculty of Medicine, Marmara University, Istanbul, Turkey
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Lee JY, Kim HC, Huh JW, Sim WS, Lim HY, Lee EK, Park HG, Bang YJ. Incidence and risk factors for rectal pain after laparoscopic rectal cancer surgery. J Int Med Res 2017; 45:781-791. [PMID: 28415928 PMCID: PMC5536646 DOI: 10.1177/0300060517693421] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2016] [Accepted: 01/21/2017] [Indexed: 12/25/2022] Open
Abstract
Objective This study was performed to investigate the incidence of and potential risk factors for rectal pain after laparoscopic rectal cancer surgery. Methods We retrospectively analyzed data from 300 patients who underwent laparoscopic rectal cancer surgery. We assessed the presence of rectal pain and categorized patients into Group N (no rectal pain) or Group P (rectal pain). Results In total, 288 patients were included. Of these patients, 39 (13.5%) reported rectal pain and 14 (4.9%) had rectal pain that persisted for >3 months. Univariate analysis revealed that patients in Group P had more preoperative chemoradiotherapy, more ileostomies, longer operation times, more anastomotic margins of <2 cm from the anal verge, more anastomotic leakage, and longer hospital stays. Multivariate analysis identified an anastomotic margin of <2 cm from the anal verge and a long operation time as risk factors. The presence of diabetes mellitus was a negative predictor of rectal pain. Conclusions In this study, the incidence of rectal pain after laparoscopic rectal cancer surgery was 13.5%. An anastomotic margin of <2 cm from the anal verge and a long operation time were risk factors for rectal pain. The presence of diabetes mellitus was a negative predictor of rectal pain. Thus, the possibility of postoperative rectal pain should be discussed preoperatively with patients with these risk factors.
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Affiliation(s)
- Jin Young Lee
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University, School of Medicine, Seoul, Korea
| | - Hee Cheol Kim
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University, School of Medicine, Seoul, Korea
| | - Jung Wook Huh
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University, School of Medicine, Seoul, Korea
| | - Woo Seog Sim
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University, School of Medicine, Seoul, Korea
| | - Hyun Young Lim
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University, School of Medicine, Seoul, Korea
| | - Eun Kyung Lee
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University, School of Medicine, Seoul, Korea
| | - Hui Gyeong Park
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University, School of Medicine, Seoul, Korea
| | - Yu Jeong Bang
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University, School of Medicine, Seoul, Korea
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Marker DR, U-Thainual P, Ungi T, Flammang AJ, Fichtinger G, Iordachita II, Carrino JA, Fritz J. MR-guided perineural injection of the ganglion impar: technical considerations and feasibility. Skeletal Radiol 2016; 45:591-7. [PMID: 26791162 DOI: 10.1007/s00256-016-2333-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2015] [Revised: 01/03/2016] [Accepted: 01/07/2016] [Indexed: 02/02/2023]
Abstract
OBJECTIVE Perineural ganglion impar injections are used in the management of pelvic pain syndromes; however, there is no consensus regarding the optimal image guidance. Magnetic resonance imaging (MRI) provides high soft tissue contrast and the potential to directly visualize and target the ganglion. The purpose of this study was to assess the feasibility of MR-guided percutaneous perineural ganglion impar injections. MATERIALS AND METHODS Six MR-guided ganglion impar injections were performed in six human cadavers. Procedures were performed with a clinical 1.5-Tesla MRI system through a far lateral transgluteus approach. Ganglion impar visibility, distance from the sacrococcygeal joint, number of intermittent MRI control steps required to place the needle, target error between the intended and final needle tip location, inadvertent punctures of non-targeted vulnerable structures, injectant distribution, and procedure time were determined. RESULTS The ganglion impar was seen on MRI in 4/6 (66 %) of cases and located 0.8 mm cephalad to 16.3 mm caudad (average 1.2 mm caudad) to the midpoint of the sacrococcygeal joint. Needle placement required an average of three MRI control steps (range, 2-6). The average target error was 2.2 ± 2.1 mm. In 6/6 cases (100 %), there was appropriate periganglionic distribution and filling of the presacrococcygeal space. No punctures of non-targeted structures occurred. The median procedure time was 20 min (range, 12-29 min). CONCLUSION Interventional MRI can visualize and directly target the ganglion impar for accurate needle placement and successful periganglionic injection with the additional benefit of no ionizing radiation exposure to patient and staff. Our results support clinical evaluation.
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Affiliation(s)
- David R Marker
- Russell H. Morgan Department of Radiology and Radiological Science, Musculoskeletal Radiology, Johns Hopkins University School of Medicine, 601 North Caroline Street, JHOC 3140A, Baltimore, MD, 21287, USA
| | - Paweena U-Thainual
- Department of Mechanical and Materials Engineering, Queen's University, 99 University Avenue, Kingston, ON, Canada
| | - Tamas Ungi
- School of Computing, Queen's University, 557 Goodwin Hall, Queen's University, Kingston, ON, Canada
| | - Aaron J Flammang
- Siemens Corporate Research, Center for Applied Medical Imaging, Baltimore, MD, USA
| | - Gabor Fichtinger
- School of Computing, Queen's University, 557 Goodwin Hall, Queen's University, Kingston, ON, Canada
| | - Iulian I Iordachita
- Department of Mechanical Engineering and Laboratory for Computational Sensing and Robotics, Johns Hopkins University, 3400 N. Charles St., Hackerman 112, Baltimore, MD, 21218, USA
| | - John A Carrino
- Russell H. Morgan Department of Radiology and Radiological Science, Musculoskeletal Radiology, Johns Hopkins University School of Medicine, 601 North Caroline Street, JHOC 3140A, Baltimore, MD, 21287, USA
| | - Jan Fritz
- Russell H. Morgan Department of Radiology and Radiological Science, Musculoskeletal Radiology, Johns Hopkins University School of Medicine, 601 North Caroline Street, JHOC 3140A, Baltimore, MD, 21287, USA.
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