Sonographic Nerve Tracking in the Cervical Region: A Pictorial Essay and Video Demonstration

Evaluation of the efficacy of ultrasound-guided selective cervical nerve root pulsed radiofrequency treatment in patients with chronic cervical radicular pain

PURPOSE

Management of cervical radicular pain is complex and may be resistant to conservative treatment. The primary aim of this study was to evaluate the efficacy of ultrasound-guided selective cervical nerve root pulsed radiofrequency (US-SCNR PRF) treatment in patients with radicular neck pain due to cervical disc herniation who did not respond to conservative treatment. The secondary aim was to determine the efficacy of the treatment in terms of functionality, neuropathic pain, and treatment-related adverse events.

METHODS

This study included 62 patients with chronic cervical radicular pain who underwent US-SCNR PRF treatment. Pain intensity was assessed using the Numerical Rating Scale before treatment and at 1, 3, and 6 months after treatment. The Neck Disability Index and Douleur Neuropathique 4 Questions were used to assess functionality and neuropathic pain before and 6 months after treatment. Significant pain relief was defined as ≥ 50% reduction in the pain score compared with the pre-treatment score.

RESULTS

Cervical radicular pain was significantly reduced at 1, 3, and 6 months after pulsed radiofrequency compared to pre-treatment (P < 0.001). Successful pain relief was achieved in 59.6% of the patients at 6 month. However, there was no significant difference between the mean pain scores in the 1st month, 3rd month and 6th month. In addition, the functionality and neuropathic pain scores were significantly reduced at 6 month.

CONCLUSIONS

These results suggest that US-SCNR PRF treatment is effective for cervical radicular pain, functionality, and neuropathic pain for at least six months in the majority of patients with refractory cervical radicular pain, and is considered a safer and preferable treatment modality due to real-time visualization of the cervical nerve roots and adjacent neurovascular structures and no radiation exposure.

Pictorial Essay on Ultrasound and Magnetic Resonance Imaging of Paraspinal Muscles for Myofascial Pain Syndrome

The paraspinal muscles of the cervical, thoracic, and lumbar spine are important pain generators because muscle strains or myofascial pain syndrome caused by trigger points are common during clinical practice. Ultrasonography is the most convenient imaging tool for evaluating these muscles due to its advantages, such as providing good delineation of soft tissues, easy accessibility, and zero radiation. Additionally, ultrasound can serve as a useful guiding tool for paraspinal muscle intervention to prevent inadvertent injuries to vital axial neurovascular structures. This pictorial essay presents ultrasound scanning protocols for the paraspinal and other associated muscles as well as a discussion of their clinical relevance. Axial magnetic resonance imaging has also been used to elucidate reciprocal anatomy. In conclusion, ultrasound imaging proves to be a valuable tool that facilitates the differentiation of individual paraspinal muscles. This capability significantly enhances the precision of interventions designed to address myofascial pain syndrome.

Feasibility study of ultrasound-guided percutaneous laser discectomy for cervical radicular pain

Percutaneous laser discectomy is one common and effective treatment for cervical radicular pain. Currently, the surgery is performed with blind cannulation technique, mainly relies on the experience of surgeon. However, it still remains unsafe and difficult to reach the target. As an alternative, ultrasound-guided cannulation provides visualization of important structures, thus increasing the precision and safety. The primary goal of this study is to report the detail of the ultrasound-guided technique in the percutaneous laser cervical discectomy. The secondary purpose is to evaluate the feasibility of the novel therapy. This is a single center, feasibility study conducted in one teaching hospital. Thirteen intervertebral discs in 9 patients presented with cervical radicular pain. Accuracy of the cannulation with ultrasonic guidance was confirmed by the anterior-posterior and lateral view of fluoroscopy. We compared the pain severity pre- and post-treatment with Visual Analogue Score (VAS), and functional improvement was assessed with the modified Macnab Criteria and Neck Disability Index (NDI) respectively. Ultrasonic short-axis was used to scan the cervical nerve root, and its transition was used to identify the distinct intervertebral space. Following the recognition of targeted cervical level, the ultrasound probe was moved medially for the visualization of the surface of the cervical vertebrae. In plane cannulation was then applied to avoid the injury of the vessels. The location of cannula was confirmed by the fluoroscopic imaging. Low-power laser was set for the cervical disc ablation in this cohort. The majority of the surgical sites maintained in the C5/6 level (38%), and 31% for the C6/7 level respectively. Despite the distinct cervical level, the tip of needle was properly placed near by the targeted intervertebral disc in all participants, which was confirmed by the imaging of fluoroscopy. We did not observe any obvious complications during the procedure. The mean VAS decreased from 7.6 ± 1.1 to 2.3 ± 2.7 one month after discharge, and 2.1 ± 2.6 at the last follow-up (median duration of nine months). All patients reported significant improvement of NDI up to last follow-up (p = 0.011). Meanwhile, the good to excellent rate was reported in 8 of 9 patients (89%) according to the modified Macnab Criteria. The finding of this feasibility assessment indicates the ultrasound-based cannulation technique is capable of guiding the cannulation for the percutaneous laser discectomy. It may facilitate identifying the corresponding site of cervical intervertebral disc and prevent the damage of vessel.

Ultrasound of Small Nerves

Nerve ultrasound has become an integral part of the diagnostic workup of peripheral neuropathies. Especially in the examination of small nerves, ultrasound provides superior image quality by using high frequency transducers. For a selection of small nerves, this article summarizes the local anatomy and common pathologies and offers simple instructions for determining their location with ultrasound including some cases with pathologies. This selection of nerves comprises the great auricular nerve, the supraclavicular nerves, the suprascapular nerve, the medial antebrachial cutaneous nerve, the lateral antebrachial cutaneous nerve, the palmar cutaneous branch of the median nerve, the long thoracic nerve, the intercostobrachial nerve, the posterior cutaneous nerve, the infrapatellar branch of the saphenous nerve, the medial calcaneal nerve, and the deep peroneal nerve at the ankle. Following our recommendations, these nerves can be swiftly located and tracked along their course to the site of the pathology.

Ultrasound-Guided Procedures in the Cervical Spine

Cervical pain is a common symptom among the general population. When conservative strategies fail to provide pain relief, cervical spine injections may be considered. Compared with cervical surgery, cervical injections have low major complications and, with the right indication, have demonstrated good results. Traditionally, these types of procedures have been performed under fluoroscopy; however, in recent years, ultrasound has become a more common imaging modality to guide spinal injections. Although ultrasound presents an excellent quality image for soft tissue and allows ​the observation of vascular tissues, nerves, and the contour of bone surfaces, the cervical region has a complicated neurovascular network and a comprehensive understanding of the cervical sonoanatomy should remain as the basis before one can plan cervical ultrasound-guided intervention. This paper aims to show the advantages of ultrasound in facilitating the performance of cervical spine procedures, including facet joint injections, medial branch blocks, and selective nerve root blocks; analyze the sonoanatomy and landmarks of commonly intervened cervical structures; and illustrate how these procedures can be performed safely and precisely under ultrasound guidance.

Ultrasound Localization and Percutaneous Electrical Stimulation of the Hypoglossal Nerve and Ansa Cervicalis

OBJECTIVE

Hypoglossal nerve stimulation for obstructive sleep apnea (OSA) can be effective for appropriately selected patients, but current patient selection criteria are complex and still result in a proportion of nonresponders. Ansa cervicalis stimulation of the infrahyoid cervical strap muscles has recently been proposed as a new form of respiratory neurostimulation (RNS) therapy for OSA treatment. We hypothesized that percutaneous stimulation of both nerves in humans with temporary electrodes would make testing of the physiologic response to different RNS strategies possible.

STUDY DESIGN

Nonrandomized acute physiology study.

SETTING

Tertiary care hospital.

METHODS

Fifteen participants with OSA underwent ultrasonography and placement of percutaneous electrodes proximal to the medial division of the hypoglossal nerve and the branch of the ansa cervicalis innervating the sternothyroid muscle (ACST). Procedural success was documented in each participant, as were any failures or procedural complication.

RESULTS

The hypoglossal nerve was successfully localized in 15 of 15 (100%) participants and successfully stimulated in 13 of 15 (86.7%). The ACST was successfully localized in 15 of 15 (100%) participants and successfully stimulated in 14 of 15 (93.3%). Stimulation failure of the hypoglossal nerve was due to suboptimal electrode placement in 1 participant and electrode displacement in the other 2 cases. No complications occurred.

CONCLUSIONS

The hypoglossal nerve and ACST can be safely stimulated via percutaneous electrode placement. Larger trials of percutaneous stimulation may help to identify responders to different RNS therapies for OSA with temporary or permanent percutaneous electrodes. Techniques for electrode design, nerve localization, and electrode placement are described.

Ansa Cervicalis Stimulation: A New Direction in Neurostimulation for OSA

BACKGROUND

Hypoglossal nerve stimulation (HNS) is an alternative treatment option for patients with OSA unable to tolerate positive airway pressure but implant criteria limit treatment candidacy. Previous research indicates that caudal tracheal traction plays an important role in stabilizing upper airway patency.

RESEARCH QUESTION

Does contraction of the sternothyroid muscle with ansa cervicalis stimulation (ACS), which pulls the pharynx caudally via thyroid cartilage insertions, increase maximum inspiratory airflow (V_Imax)?

STUDY DESIGN AND METHODS

Hook-wire percutaneous electrodes were used to stimulate the medial branch of the right hypoglossal nerve and right branch of the ansa cervicalis innervating the sternothyroid muscle during propofol sedation. V_Imax was assessed during flow-limited inspiration with a pneumotachometer.

RESULTS

Eight participants with OSA were studied using ACS with and without HNS. Compared with baseline, the mean V_Imax increase with isolated ACS was 298%, or 473 mL/s (95% CI, 407-539). Isolated HNS increased mean V_Imax from baseline by 285%, or 260 mL/s (95% CI, 216-303). Adding ACS to HNS during flow-limited inspiration increased mean V_Imax by 151%, or 205 mL/s (95% CI, 174-236) over isolated HNS. Stimulation was significantly associated with increase in V_Imax in both experiments (P < .001).

INTERPRETATION

ACS independently increased V_Imax during propofol sedation and drove further increases in V_Imax when combined with HNS. The branch of the ansa cervicalis innervating the sternothyroid muscle is easily accessed. Confirmation of the ansa cervicalis as a viable neurostimulation target may enable caudal pharyngeal traction as a novel respiratory neurostimulation strategy for treating OSA.

Sonographic Pearls for Imaging the Brachial Plexus and Its Pathologies

The brachial plexus (BP) is a complicated neural network, which may be affected by trauma, irradiation, neoplasm, infection, and autoimmune inflammatory diseases. Magnetic Resonance Imaging is the preferred diagnostic modality; however, it has the limitations of high cost and lack of portability. High-resolution ultrasound has recently emerged as an unparalleled diagnostic tool for diagnosing postganglionic lesions of the BP. Existing literature describes the technical skills needed for prompt ultrasound imaging and guided injections for the BP. However, it remains particularly challenging for beginners to navigate easily while scanning its different parts. To address this, we share several “clinical pearls” for the sonographic examination of the BP as well as its common pathologies.

Ultrasound imaging and guidance in peripheral nerve entrapment: hydrodissection highlighted

Ultrasound (US) imaging has become one of the most useful modalities to assess peripheral nerve disorders. Nowadays, it is as important as nerve conduction studies and electromyography for peripheral nerve entrapment. Additionally, US is also helpful in guiding a possible intervention. As peripheral nerves are tiny, palpation-guided injections are really challenging for precisely targeting the nerves. By using US, perineural injections have significantly become safe and effective. Recently, US-guided hydrodissection has emerged as the mainstream for nerve entrapment. Accordingly, this review aims to summarize and update the mechanism and evidence regarding this imperative procedure for neuropathic pain management. Furthermore, the pathogenesis, anatomic features, US findings and histological correlations of nerve entrapment syndromes will also be discussed in this article.

Ultrasound-Guided Superior and Middle Trunk Brachial Plexus Block with Superficial Cervical Plexus Block for Shoulder Surgeries in High-Risk Patients: Case Series

There is a constant quest for a regional anesthetic technique that would provide anesthesia adequately for shoulder surgeries but lacks the complications of an interscalene block, such as phrenic nerve palsy. The nerves to be blocked for a surgery can be analyzed and tailored. We discuss the precise blockade of the superior and middle trunk of the brachial plexus along with superficial cervical plexus block using ultrasound for performing three different shoulder surgeries exclusively under regional anesthesia, in high-risk patients without any clinically observed complications.

Musculoskeletal ultrasound workshops in postgraduate physician training: a pre- and post-workshop survey of 156 participants

BACKGROUND

Use of ultrasonography has revolutionized diagnosis of musculoskeletal disorders. Until now, few studies have investigated usefulness of a short-period workshop for musculoskeletal ultrasound (MSKUS) education. In this research, we attempted to explore (1) whether the physicians felt it useful to attend this type of courses for improving knowledge of sonoanatomy and scanning skills, (2) if the attendees' perceived confidence in musculoskeletal diagnoses by using ultrasound increased following the program and (3) whether differences existed in perceived usefulness and confidence regrading different sessions of the course.

METHODS

The target participants of the courses were postgraduate physicians without limitation of their specialties. The attendees' responses to questionnaires before and after the course were reviewed. The workshop contained didactic and practical sessions on 6 major joints in accordance with the scanning protocols of EURO-MUSCULUS/USPRM. The course usefulness and perceived confidence in MSKUS examination were evaluated using a 5-point Likert scale. Data relevant to participants' pre-workshop confidence levels were also analyzed. If any participant attended the course for more than 1 time, only their first survey was used for analysis.

RESULTS

The study included 156 participants. The average rating for the course usefulness ranged between 4 (useful) to 5 (very useful). There was no difference in perceived usefulness between the didactic and hands-on practical sessions. Participants' perceived confidence significantly increased after the workshop but appeared to be lowest for evaluation on the hip joint. Previous experience in performing MSKUS (in years) was consistently associated with the level of pre-workshop confidence.

CONCLUSION

A short period ultrasound workshop might be useful regarding making musculoskeletal diagnoses by using ultrasound based on an increase in post-workshop confidence in MSKUS examinations. The perceived confidence of hip scanning was lower than that of other joints after the course, indicating inadequacy of education in hip sonoanatomy and intensity of hand-on practice in the present program. An increase in the faculty-to-student ratio or length of practice in the hip section should be implemented in the future course.

Ultrasound imaging of the upper trapezius muscle for safer myofascial trigger point injections: a case report

Chronic myofascial pain of the cervical spine and shoulders is commonplace in clinical practice and is often related to adverse posture during work conditions in our lifestyle. The diagnosis is clinical and injections of the neck/shoulder muscles, especially the upper trapezius, are commonly performed in a blinded way. The anatomy of the posterior compartment of the neck is complicated, and several neurovascular structures are located nearby the trapezius and levator scapulae muscles in the inter-fascial planes. In this case of ours, we describe in details the sono-anatomy of the lower neck and propose a posterior ultrasound-guided real-time in-plane approach to inject the muscle belly of the upper trapezius, i.e. avoiding the superficial and deep branches of the transverse cervical artery and the spinal accessory nerve.

Toward a Consensus for Musculoskeletal Ultrasonography Education in Physical Medicine and Rehabilitation: A National Poll of Residency Directors

OBJECTIVES

The aims of the study were to evaluate integration of musculoskeletal ultrasonography education in physical medicine and rehabilitation training programs in 2014-2015, when the American Academy of Physical Medicine & Rehabilitation and Accreditation Council for Graduate Medical Education Residency Review Committee both recognized it as a fundamental component of physiatric practice, to identify common musculoskeletal ultrasonography components of physical medicine and rehabilitation residency curricula, and to identify common barriers to integration.

DESIGN

Survey of 78 Accreditation Council for Graduate Medical Education-accredited physical medicine and rehabilitation residency programs was conducted.

RESULTS

The 2015 survey response rate was more than 50%, and respondents were representative of programs across the United States. Most programs (80%) reported teaching musculoskeletal ultrasonography, whereas a minority (20%) required mastery of ultrasonography skills for graduation. Ultrasonography curricula varied, although most programs agreed that the scope of resident training in physical medicine and rehabilitation should include diagnostic and interventional musculoskeletal ultrasonography, especially for key joints (shoulder, elbow, knee, wrist, hip, and ankle) and nerves (median, ulnar, fibular, tibial, radial, and sciatic). Barriers to teaching included insufficient expertise of instructors, poor access to equipment, and lack of a structured curriculum.

CONCLUSIONS

Musculoskeletal ultrasonography has become a required component of physical medicine and rehabilitation residency training. Based on survey responses and expert recommendations, we propose a structure for musculoskeletal ultrasonography curricular standards and milestones for trainee competency.

Endogenous Neurostimulation and Physiotherapy in Cluster Headache: A Clinical Case

OBJECTIVE

The aim of this paper is to describe the progressive changes of chronic cluster headaches (CHs) in a patient who is being treated by a multimodal approach, using pharmacology, neurostimulation and physiotherapy.

SUBJECT

A male patient, 42 years of age was diagnosed with left-sided refractory chronic CH by a neurologist in November 2009. In June 2014, the patient underwent a surgical intervention in which a bilateral occipital nerve neurostimulator was implanted as a treatment for headache.

METHODS

Case report.

RESULTS

Primary findings included a decreased frequency of CH which lasted up to 2 months and sometimes even without pain. Besides this, there were decreased levels of anxiety, helplessness (PCS subscale) and a decreased impact of headache (HIT-6 scale). Bilateral pressure pain thresholds (PPTs) were improved along with an increase in strength and motor control of the neck muscles. These improvements were present at the conclusion of the treatment and maintained up to 4 months after the treatment.

CONCLUSIONS

A multimodal approach, including pharmacology, neurostimulation and physiotherapy may be beneficial for patients with chronic CHs. Further studies such as case series and clinical trials are needed to confirm these results.

Ultrasound Imaging for the Cutaneous Nerves of the Extremities and Relevant Entrapment Syndromes: From Anatomy to Clinical Implications

Cutaneous nerve entrapment plays an important role in neuropathic pain syndrome. Due to the advancement of ultrasound technology, the cutaneous nerves can be visualized by high-resolution ultrasound. As the cutaneous nerves course superficially in the subcutaneous layer, they are vulnerable to entrapment or collateral damage in traumatic insults. Scanning of the cutaneous nerves is challenging due to fewer anatomic landmarks for referencing. Therefore, the aim of the present article is to summarize the anatomy of the limb cutaneous nerves, to elaborate the scanning techniques, and also to discuss the clinical implications of pertinent entrapment syndromes of the medial brachial cutaneous nerve, intercostobrachial cutaneous nerve, medial antebrachial cutaneous nerve, lateral antebrachial cutaneous nerve, posterior antebrachial cutaneous nerve, superficial branch of the radial nerve, dorsal cutaneous branch of the ulnar nerve, palmar cutaneous branch of the median nerve, anterior femoral cutaneous nerve, posterior femoral cutaneous nerve, lateral femoral cutaneous nerve, sural nerve, and saphenous nerve.

Ultrasound-guided versus low dose computed tomography scanning guidance for lumbar facet joint injections: same accuracy and efficiency

BACKGROUND

The purpose of this study was to investigate the feasibility, accuracy and efficiency of the facet joint injections in the lumbar spine by ultrasound guided versus lose dose computed tomography (CT) guidance.

METHODS

First the examination on the joint space of the facet joints of the lumbar spine was obtained by the ultrasound in 10 patients. Second forty patients were randomized assigned into two groups: ultrasound group and low dose CT group. Comparison was made in the clinical efficiency between the ultrasound-guided group and CT group. The feasibility, accuracy and efficiency of the ultrasound-guided lumbar facet joint injections were also evaluated.

RESULTS

A total of 88 lumbar facet joints from L1 to S1 were clearly visualized in the 10 patients. Both the ultrasound and the CT measurements showed the same average depth and lateral distance to the reference point (P > 0.05). And 86.5% of the facet joint injections (64/74) were correctly performed under the ultrasound guidance in the first time. The exact placement of the needle tips was evaluated by CT. After the lumbar facet joint injections, the clinical efficiency was almost the same in the ultrasound-guided group as in the CT group.

CONCLUSIONS

The lumbar facet joint space can be accurately demonstrated by ultrasound. The ultrasound-guided facet joint injection in the lumbar spine obtained almost the same satisfactory feasibility, accuracy and clinical efficiency compared with low dose CT. Ultrasound technique could provide the real-time monitoring.

TRIAL REGISTRATION

This study was registered on Chinese Clinical Trial Registry ( ChiCTR1800018819 , retrospective registered on 11/10/2018).

Anatomical variants of dorsal scapular nerve in relation to the middle scalene muscle in Japanese population

Dorsal scapular nerve (DSN) block is often performed in Japanese pain clinics to treat neck pain and katakori (a unique symptom in Japanese population characterized by myofascial pain syndromes such as shoulder girdle pain). However, to the best of our knowledge, there are only a few studies regarding anatomical variations in DSN paths around the middle scalene muscle (MSM) in Japanese population. Thus, we conducted a cadaveric study to examine anatomical variations in DSN paths around the MSM in Japanese population.DSN anatomies of 70 adult Japanese cadavers used for research and gross anatomy practice at the Tokai University School of Medicine between 2015 and 2016 were examined.In all cadavers, DSNs originated from the brachial plexus (BP) and innervated the rhomboid major, rhomboid minor, and levator scapulae muscles via the MSM. Two types of DSN paths were observed: piercing-type (piercing the MSM) and anterior-type (running in front of the MSM). We surveyed all 140 sides in 70 Japanese cadavers; of these, 95 sides had piercing-type and 45 had anterior-type paths. Of the 70 cadavers, 42 had piercing-type and 17 had anterior-type paths on both the sides. In 9 cadavers, the left and right sides had piercing-type and anterior-type paths, respectively. In the other 2 cadavers, the right and left sides had piercing-type and anterior-type paths, respectively.We found 2 distinct anatomical variants for DSN paths around the MSM in this Japanese cohort. Our results suggest that the rate of anterior-type DSN path is higher in Japanese population. Therefore, it is necessary to maintain caution while injecting anesthetic agents during a DSN block and the type of DSN should be considered.

Basis of Shoulder Nerve Entrapment Syndrome: An Ultrasonographic Study Exploring Factors Influencing Cross-Sectional Area of the Suprascapular Nerve

As changes in nerves' shape and size are common ultrasonographic findings of entrapment neuropathy, measurement of the nerve cross-sectional area (CSA) becomes the mostly used indicator to differentiate normality from pathology. Recently, more US research has been conducted to measure the shape of the suprascapular notch and the diameter of the suprascapular nerve. Because the suprascapular nerve is paramount for various shoulder disorders, the present study aims to establish normal values of suprascapular nerve sizes at different levels as well as to investigate potential influence of participants' characteristics on the CSA measurements. The present study used a cross-sectional design investigating the CSA values of the suprascapular nerve from the supraclavicular region to spinoglenoid notch. We employed the inside-epineurium and outside-epineurium methods to quantify CSA of cervical roots (C5 and C6) and the suprascapular nerve on US imaging. Univariate comparisons of nerve sizes among different age and gender groups were carried out. Multivariate analysis was performed to analyze the impact of participants' characteristics on nerve CSA. Repeated measurement analysis of variance was conducted to examine segmental variations of CSA of the suprascapular nerve from its origin to infraspinatus fossa. Our study included 60 healthy adults with 120 shoulders and had three major findings: (1) the inside-epineurium method was more reliable than the outside-epineurium approach for CSA measurements due to higher intra- and inter-rater reliability, (2) women had smaller sizes for cervical nerve roots and for the most proximal segment of the suprascapular nerves, and (3) using the outside-epineurium method, the suprascapular nerve CSA was larger in its distal division than the portion proximal to the mid-clavicular line. In conclusion, the inside-epineurium method has better reliability for nerve CSA assessment but the outside-epineurium method is needed for quantifying the size of distal suprascapular nerve. Gender difference in CSA values should be considered during evaluation of the most proximal nerve segment. Using the outside-epineurium method, the distal suprascapular nerve would be estimated larger than its proximal portion and the segmental discrepancy should be not misinterpreted as pathology.

Cross-talk between shoulder and neck pain: an imaging study of association between rotator cuff tendon tears and cervical foraminal stenosis

Rotator cuff tendon tears are prevalent in patients with shoulder pain, the third most common musculoskeletal complaint. As shoulders are largely innervated by cervical nerves, it seems possible that rotator cuff pathology could have an association with cervical spine disorders, although few studies have investigated this possibility. This study aimed to explore the association between rotator cuff tendon tears and cervical radiculopathy (at C5 and C6 levels) in the shoulder pain population.We conducted a retrospective review of a clinical registry of shoulder ultrasound (US) examinations and cervical spine radiographs, recruiting a total of 126 patients with cervical spine radiographs taken within 1 year of US examinations. Foraminal stenosis was grouped into 4 categories: C4/5 intervertebral foramen only, C5/6 intervertebral foramen only, both C4/5 and C5/6 intervertebral foramina, and neither C4/5 nor C5/6 intervertebral foramen. The groups with and without rotator cuff tendon tears were compared for various factors, using the Mann-Whitney U test for continuous variables and the χ test for categorical variables. A multivariate analysis was conducted using a logistic regression model to investigate the association between rotator cuff tendon tears and cervical foraminal stenosis.Patients with rotator cuff tendon tears tended to be older and had more night-time pain. No significant association was identified between rotator cuff tendon tears and cervical foraminal stenosis at C5 and C6 levels. The only factor significantly predicting rotator cuff tendon tears was old age (odds ratio, 1.04; 95% confidence interval: 1.00-1.09).In patients with shoulder or neck pain, no significant association existed between rotator cuff tendon tears and cervical foraminal stenosis (at the C5 and C6 levels). When patients present with undifferentiated shoulder and neck pain, physicians should take a detailed history, perform physical examinations and imaging studies of both the neck and shoulder regions.

Can ultrasound be an assessment tool for sagittal spine mobility and chest expansion in patients with ankylosing spondylitis?

We aimed to examine whether ultrasound (US) is useful for evaluating spinal mobility and chest expansion in ankylosing spondylitis (AS) patients and determine a cutoff value to identify reduced sagittal lumbar mobility.Our cross-sectional study included 50 AS patients and 50 controls. Metric measurements and Bath AS indices were measured in AS patients. The distance between C6-C7, T11-T12, and L4-L5 vertebrae was measured, and the difference and percentage of difference between erect position and maximal cervical and lumbar flexion was calculated (T11-T12dif, T11-T12%, L4-L5dif, L4-L5%, T+L dif, T+L%). Intercostal divergence was measured 1.5 cm away on the left from the sternocostal space during maximum inhalation and maximum exhalation, and the difference and percentage of difference between them was calculated (ICdif, IC%).All metric measurements were lower in the AS group except for tragus-to-wall distance. T11-T12dif, T11-T12%, L4-L5dif, T+L dif, and T+L% values were higher in the control group, while other US measurements did not differ between the groups. All US measurements except ICdif and IC% correlated with the Bath AS Metrology Index.Thus, US may be used for assessing spinal mobility in patients with AS. T11-T12dif <0.79 cm may show decreased lumbar sagittal mobility.

Ultrasound-Guided Interventions of the Cervical Spine and Nerves

High-resolution ultrasound (US) enables prompt depiction of muscles, tendons, ligaments, and peripheral nerves. It seems to be the best imaging modality for guiding perineural injections. The most complicated neurovascular network of the musculoskeletal system surrounds the cervical spine; so injection to that region is never an easy task. This article elaborates the regional anatomy and the use of US scanning and guidance for cervical interventions; for example, cervical root, superficial cervical plexus, stellate ganglion, cervical medial branch, greater occipital nerve, and third occipital nerve. The article aims to lead readers to practice US-guided cervical injections precisely and safely.

Sonographic tracking of trunk nerves: essential for ultrasound-guided pain management and research

Delineation of architecture of peripheral nerves can be successfully achieved by high-resolution ultrasound (US), which is essential for US-guided pain management. There are numerous musculoskeletal pain syndromes involving the trunk nerves necessitating US for evaluation and guided interventions. The most common peripheral nerve disorders at the trunk region include thoracic outlet syndrome (brachial plexus), scapular winging (long thoracic nerve), interscapular pain (dorsal scapular nerve), and lumbar facet joint syndrome (medial branches of spinal nerves). Until now, there is no single article systematically summarizing the anatomy, sonographic pictures, and video demonstration of scanning techniques regarding trunk nerves. In this review, the authors have incorporated serial figures of transducer placement, US images, and videos for scanning the nerves in the trunk region and hope this paper helps physicians familiarize themselves with nerve sonoanatomy and further apply this technique for US-guided pain medicine and research.