Spinal Cord Stimulation for Post Total Knee Replacement Pain: A Case Series

It is not uncommon for orthopedic patients to experience pain following a total knee replacement (TKR). Use of oral pain medications, nerve blocks, and periarticular injections are implemented to provide multimodal analgesia and to reduce postoperative chronic pain. Spinal cord stimulation (SCS) can also be used to control pain in patients who are refractory to conservative measures. Few studies have explored this possibility for patients with chronic pain status post TKR. We present three cases that demonstrate the effectiveness of SCS in this challenging patient population.

Three Cases of COVID-19 Pneumonia That Responded to Icosapent Ethyl Supportive Treatment

BACKGROUND Icosapent ethyl, a form of eicosapentaenoic acid with anti-inflammatory activity, has been approved as an adjunctive treatment with statins in patients with hypertriglyceridemia. Icosapent ethyl is currently undergoing clinical trials to determine its anti-inflammatory effects in patients with coronavirus disease 2019 (COVID-19). This report describes 3 intensive care unit (ICU) patients with moderate to severe COVID-19 pneumonia treated with icosapent ethyl as part of their supportive care who had favorable outcomes. CASE REPORT Case 1 was a 75-year-old man with a past medical history of hyperlipidemia, hypertension, type 2 diabetes mellitus, obesity, and benign prostatic hyperplasia. Case 2 was a 23-year old man with a past medical history of type 2 diabetes mellitus and obesity. Case 3 was a 24-year old man with a history of autism. All cases of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection were confirmed from a nasopharyngeal swab using the Becton Dickinson nasopharyngeal reverse-transcription polymerase chain reaction. All patients in these cases were treated with a course of 2 g of icosapent ethyl twice a day by nasogastric tube. CONCLUSIONS This report of 3 cases describes the use of icosapent ethyl as a component of supportive treatments in ICU patients with moderate to severe COVID-19 pneumonia. However, as of yet there are no evidence-based treatments for SARS-CoV-2 infection from controlled clinical trials. The outcomes of ongoing clinical trials are awaited to determine whether icosapent ethyl has anti-inflammatory effects in patients with SARS-CoV-2 infection and which patients might benefit from the use of this adjunctive treatment.

Use of Dexmedetomidine With Dexamethasone for Extended Pain Relief in Adductor Canal/Popliteal Nerve Block During Achilles Tendon Repair

The use of regional anesthetic techniques in the peri-operative period has increased as a means to improve analgesia and patient outcomes. Traditionally, various local anesthetics are used and addition of adjuncts such as epinephrine, clonidine, and dexamethasone has shown to prolong the block effect. There has been ongoing research to support the prolongation of a regional block with the addition of dexamethasone and dexmedetomidine (Dex-Dex), providing analgesia for multiple days. We present a case of a 35-year-old female who underwent an Achilles tendon repair with an adductor/popliteal nerve block. Both dexmedetomidine and dexamethasone were added to the local anesthetic mixture with substantial postoperative analgesic control. The patient also did not require any supplemental opioid medication. This case emphasizes the proposed synergistic effect of dexmedetomidine and dexamethasone when added to the local anesthesia injectate for lower extremity peripheral nerve blocks.

Cannabis and cannabidiol (CBD) for the treatment of fibromyalgia

Fibromyalgia is a complex disease process that is as prevalent as it is poorly understood. Research into the pathophysiology is ongoing, and findings will likely assist in identifying new therapeutic options to augment those in existence today that are still insufficient for the care of a large population of patients. Recent evidence describes the use of cannabinoids in the treatment of fibromyalgia. This study provides a systematic, thorough review of the evidence alongside a review of the seminal data regarding the pathophysiology, diagnosis, and current treatment options. Fibromyalgia is characterized by widespread chronic pain, fatigue, and depressive episodes without an organic diagnosis, which may be prevalent in up to 10% of the population and carries a significant cost in healthcare utilization, morbidity, a reduced quality of life, and productivity. It is frequently associated with psychiatric comorbidities. The diagnosis is clinical and usually prolonged, and diagnostic criteria continue to evolve. Some therapies have been previously described, including neuropathic medications, milnacipran, and antidepressants. Despite some level of efficacy, only physical exercise has strong evidence to support it. Cannabis has been used historically to treat different pain conditions since ancient times. Recent advances allowed for the isolation of the active substances in cannabis and the production of cannabinoid products that are nearly devoid of psychoactive influence and provide pain relief and alleviation of other symptoms. Many of these, as well as cannabis itself, are approved for use in chronic pain conditions. Evidence supporting cannabis in chronic pain conditions is plentiful; however, in fibromyalgia, they are mostly limited. Only a handful of randomized trials exists, and their objectivity has been questioned. However, many retrospective trials and patient surveys suggest the significant alleviation of pain, improvement in sleep, and abatement of associated symptoms. Evidence supporting the use of cannabis in chronic pain and specifically in fibromyalgia is being gathered as the use of cannabis increases with current global trends. While the current evidence is still limited, emerging data do suggest a positive effect of cannabis in fibromyalgia. Cannabis use is not without risks, including psychiatric, cognitive, and developmental as well as the risks of addiction. As such, clinical judgment is warranted to weigh these risks and prescribe to patients who are more likely to benefit from this treatment. Further research is required to define appropriate patient selection and treatment regimens.

Cannabidiol (CBD) as a treatment of acute and chronic back pain: A case series and literature review

OBJECTIVE

Two patient case reports are presented describing the use of cannabidiol (CBD) for the symptomatic relief of a lumbar compression fracture and in the mitigation of thoracic discomfort and dysesthesia secondary to a surgically resected meningioma.

DISCUSSION

CBD appears to have antisnociceptive and anti-inflammatory effects on opioid-naive patients with neuro-pathic and radicular pain. Of note, the patients in this case series used the same CBD cream: Baskin Essentials Body Wellness Cream (400 mg CBD per two oz.) Conclusion: Hemp-derived CBD in a transdermal cream provided significant symptom and pain relief for the patients described in this case series. Based on these results, we believe further investigation is warranted to see if CBD-containing products should have a more prominent role in the treatment of acute and chronic pain.

Does promethazine shorten the length of stay in the post anesthesia care unit?

The combination of promethazine and opioids is known to have an opioid-sparing effect, thereby facilitating a reduction in total patient opioid consumption. In recent years, this practice has fallen out of favor in many healthcare facilities, except primarily in the post anesthesia care unit (PACU). The goal of this study was to highlight the potential of promethazine as a direct or indirect adjuvant medication in acute pain management. The present investigation was undertaken with a case series of adult female patients who underwent open total abdominal hysterectomies. Data from the PACU was reviewed with patients being separated into two groups. Group 1 received only intravenous opioids for acute pain management. Group 2 received a combination of intravenous opioids for acute pain management and intravenous promethazine for nausea and/or vomiting. Patients were discharged from the PACU with a modified Aldrete score of 9 or 10. The study showed that patients who received promethazine in addition to opioids were discharged from the PACU an average of 19.2 minutes earlier than those patients who received only opioids (p=0.003). The time to achieve modified Aldrete score of 9 or higher was more quickly achieved when open abdominal hysterectomy patients received promethazine in addition to opioids in the PACU. The study concluded that promethazine, in combination with opioids, could potentially decrease PACU stay postoperatively. Based on the present investigation, the prospect of using promethazine in other facets of pain management are intriguing and warrant future studies. Specifically, it may be worth investigating whether promethazine is truly an adjunct in combination with opioids and to determine if there are any other antihistamines or neuroleptics which may have similar clinical effects to promethazine.

Brown-Séquard Syndrome Caused by Blunt Cervical Trauma with Radiographic Correlation

Brown-Séquard syndrome, while uncommon, is a neurological condition that classically results from the hemisection of the spinal cord as a result of a penetrating injury to the spinal cord. We present a reported case of blunt trauma causing a high-energy cervical burst fracture/dislocation with a significant cord signal change producing Brown-Séquard syndrome. In this case, the burst fracture at the level of C5 obtained from the motor vehicle accident led to the damage of the left-sided lateral spinal thalamic tract, descending lateral cortical spinal tracts, and ascending dorsal column. This is a unique case of blunt nonpenetrating trauma leading to a high-energy cervical burst fracture/dislocation causing significant cord signal change on T2-weighted magnetic resonance imaging (MRI). These physical changes produced symptoms of neurologic impairment commonly seen in those patients with Brown-Séquard syndrome.

Bow Hunter's Syndrome in a Patient with a Right Hypoplastic Vertebral Artery and a Dynamically Compressible Left Vertebral Artery

This is a case report of a 48-year-old man with multiple transient ischemic attacks and a known hypoplastic right vertebral artery (VA) who presented after a syncopal event while turning his head to the left. The objective of this study is to demonstrate the necessity of proper diagnosis and management of cerebrovascular pathology including imaging and surgical intervention in patients with known anatomical anomalies. This study was conducted at Massachusetts, United States of America. Our patient's history was significant for a hypoplastic right VA and a stenotic segment of the right VA at the C3–C4 junction. There was also degeneration of the C3–C4 facet on the left, with osteophyte formation compressing the VA, and a fusion of the C2–C3 segment. Imaging demonstrated obliteration of the left VA flow with head rotation to the left and subsequent reconstitution of flow in the neutral position. After consultation, the patient decided to proceed with surgical management with an anterior cervical discectomy and fusion at the level of C3–C4. Symptoms of vertebrobasilar insufficiency including syncopal episodes resolved after treatment. VA anomalies, although uncommon, are important to understand. Our patient presented with an anomalous right VA, as well as severe degenerative changes to the C2/C3 vertebrae that contributed to the development of Bow Hunter's syndrome. It is essential that proper monitoring and follow-up has to be carried out in patients with abnormal cerebral vasculature to minimize the occurrence of Bow Hunter's syndrome.

A case of paradoxical presentation of a postural postdural puncture headache after combined spinal-epidural anesthesia

We report a case of paradoxical presentation of a postural postdural puncture headache secondary to dural puncture with a 25-gauge Whitacre needle for combined spinal-epidural anesthesia. This 27-year-old female patient presented to the emergency department with elevated blood pressure and a global headache 9 days after administration of epidural anesthesia for a spontaneous vaginal delivery after an uncomplicated pregnancy. The patient reported that the headache was more intense when lying down and immediately improved when she sat or stood up from a recumbent position. The patient was discharged from emergency department after an improvement following treatment with labetalol, ondansetron, ketorolac, and fluid resuscitation.

Spinal Metastases from a Primary Fallopian Tube Serous Adenocarcinoma: A Case Report

Study Design Case report. Objective This case exemplifies the importance of a high index of suspicion when dealing with intractable pain and neurologic symptoms in patients with a history of cancer. Fallopian tube cancer is relatively uncommon, accounting for less than 0.2% of all female malignancies. Because of a low index of suspicion, it is often detected at an advanced stage. From an orthopedic perspective, osseous metastasis from primary fallopian tube malignancies is rare with only a few documented cases in the medical literature. Methods This case report documents a 68-year-old woman who developed back pain and leg weakness after undergoing surgical resection with adjuvant therapy of a primary fallopian tube adenocarcinoma. Her hospital course and follow-up are documented. Results Imaging revealed a compression fracture in the L1 vertebral body that when a biopsy confirmed a soft tissue diagnosis of a high-grade serous papillary adenocarcinoma of fallopian tube origin. The patient underwent a surgical decompression, posterior stabilization, and tumor debulking with postoperative resolution of her symptoms. Conclusions This is the first reported case of a spine metastasis from a fallopian tube serous carcinoma in a living patient. This case documents the diagnosis of a pathologic vertebral fracture due to metastasis of an atypical cancer.

Value of Examination Under Fluoroscopy for the Assessment of Sacroiliac Joint Dysfunction

BACKGROUND

Pain emanating from the sacroiliac (SI) joint can have variable radiation patterns. Single physical examination tests for SI joint pain are inconsistent with multiple tests increasing both sensitivity and specificity.

OBJECTIVE

To evaluate the use of fluoroscopy in the diagnosis of SI joint pain.

STUDY DESIGN

Prospective double blind comparison study.

SETTING

Pain clinic and radiology setting in urban Veterans Administration (VA) in New Orleans, Louisiana.

METHODS

Twenty-two adult men, patients at a southeastern United States VA interventional pain clinic, presented with unilateral low back pain of more than 2 months' duration. Patients with previous back surgery were excluded from the study. Each patient was given a Gapping test, Patrick (FABERE) test, and Gaenslen test. A second blinded physician placed each patient prone under fluoroscopic guidance, asking each patient to point to the most painful area. Pain was provoked by applying pressure with the heel of the palm in that area to determine the point of maximum tenderness. The area was marked with a radio-opaque object and was placed on the mark with a fluoroscopic imgage. A site within 1 cm of the SI joint was considered as a positive test. This was followed by a diagnostic injection under fluoroscopy with 1 mL 2% lidocaine. A positive result was considered as more than 2 hours of greater than 75% reduction in pain. Then, in 2-3 days this was followed by a therapeutic injection under fluoroscopy with 1 mL 0.5% bupivacaine and 40 mg methylprednisolone.

RESULTS

Each patient was reassessed after 6 weeks. The sensitivity and specificity in addition to the positive and negative predictive values were determined for both the conventional examinations, as well as the examination under fluoroscopy. Finally, a receiver operating characteristic (ROC) curve was constructed to evaluate test performance. The sensitivity and specificity of the fluoroscopic examination were 0.82 and 0.80 respectively; Positive predictive value and negative predictive value were 0.93 and 0.57 respectively. The area under ROC curve was 0.812 which is considered a "good" test; however the area under ROC for the conventional examination were between 0.52-0.58 which is considered "poor to fail".

LIMITATIONS

Variation in anatomy of the SI joint, small sample size.

CONCLUSIONS

Multiple structures of the SI joint complex can result in clinical symptoms of pain. These include intra-articular structures (degenerative arthritis, and inflammatory conditions) as well as extra-articular structures (ligaments, muscles, etc.).

The association between preoperative spinal cord rotation and postoperative C5 nerve palsy

BACKGROUND

C5 nerve palsy is a known complication of cervical spine surgery. The development and etiology of this complication are not completely understood. The purpose of the present study was to determine whether rotation of the cervical spinal cord predicts the development of a C5 palsy.

METHODS

We performed a retrospective review of prospectively collected spine registry data as well as magnetic resonance images. We reviewed the records for 176 patients with degenerative disorders of the cervical spine who underwent anterior cervical decompression or corpectomy within the C4 to C6 levels. Our measurements included area for the spinal cord, space available for the cord, and rotation of the cord with respect to the vertebral body.

RESULTS

There was a 6.8% prevalence of postoperative C5 nerve palsy as defined by deltoid motor strength of ≤ 3 of 5. The average rotation of the spinal cord (and standard deviation) was 2.8° ± 3.0°. A significant association was detected between the degree of rotation (0° to 5° versus 6° to 10° versus ≥ 11°) and palsy (point-biserial correlation = 0.94; p < 0.001). A diagnostic criterion of 6° of rotation could identify patients who had a C5 palsy (sensitivity = 1.00 [95% confidence interval, 0.70 to 1.00], specificity = 0.97 [95% confidence interval, 0.93 to 0.99], positive predictive value = 0.71 [95% confidence interval, 0.44 to 0.89], negative predictive value = 1.00 [95% confidence interval, 0.97 to 1.00]).

CONCLUSIONS

Our evidence suggests that spinal cord rotation is a strong and significant predictor of C5 palsy postoperatively. Patients can be classified into three types, with Type 1 representing mild rotation (0° to 5°), Type 2 representing moderate rotation (6° to 10°), and Type 3 representing severe rotation (≥ 11°). The rate of C5 palsy was zero of 159 in the Type-1 group, eight of thirteen in the Type-2 group, and four of four in the Type-3 group. This information may be valuable for surgeons and patients considering anterior surgery in the C4 to C6 levels.

A modified technique for dowel fibular strut graft placement and circumferential fusion in the setting of L5-S1 spondylolisthesis and multilevel degenerative disc disease

BACKGROUND

Traditional techniques for the treatment of isthmic spondylolisthesis pass a fibular dowel graft across the L5-S1 disc by using the anterior portion of the L5 body.

OBJECTIVE

To introduce a technique for the treatment of isthmic spondylolisthesis in the setting of multilevel degenerative disc disease in adults. Our modified technique allows us to traverse the L5-S1 disc via the L4-5 disc space thereby treating the degenerated disc at L4-5 simultaneously.

METHODS

A standard anterior discectomy was performed on L4-5. Using biplanar fluoroscopy, a Kirschner wire was placed beginning at the anterior third of the L5 superior endplate and ending at S1. An anterior cruciate ligament reamer was used to make a channel for the fibular allograft. Then, a femoral ring allograft was placed in the disc space at L4-5, and standard anterior lumbar interbody fusions were performed at any additional cephalad level(s). Afterward, posterior instrumented fusion was performed to complement the anterior fusion procedure (except at L5), and wide decompression followed.

RESULTS

All patients presented with isthmic spondylolisthesis and all had multilevel fusions. The mean slip angle was 32.6 degrees (37.8 degrees preoperatively), and mean lumbar index was 67%. After the procedure, the average endplate-to-dowel angle was 107.1 degrees compared with 134 degrees. All patients had clinical and radiographic evidence of solid fusion without the need for revisions.

CONCLUSION

The proposed advantage of our modified technique is twofold. The graft is placed nearly perpendicular to the L5-S1 interface, as it will behave more efficiently with respect to interfragmental compression. Also, surgeons gain access to fuse L4-5 anteriorly and posteriorly.

Use of the trauma pelvic orthotic device (T-POD) for provisional stabilisation of anterior-posterior compression type pelvic fractures: a cadaveric study

OBJECTIVE

To demonstrate that a commercially available pelvic binder the trauma pelvic orthotic device (T-POD) is an effective way to provisionally stabilise anterior-posterior compression type pelvic injuries.

METHODS

Rotationally unstable pelvic injuries were created in 12 non-embalmed human cadaveric specimens. Each pelvis was then stabilised first with a standard bed sheet wrapped circumferentially around the pelvis and held in place with a clamp. After recreating the symphyseal diastasis, the pelvis was stabilised with the T-POD. Reduction of the symphyseal diastasis was assessed by comparing measurements obtained via pre- and post-stabilisation AP radiographs.

RESULTS

The mean symphyseal diastasis was reduced from 39.3mm (95% CI 30.95-47.55) to 17.4mm (95% CI -0.14 to 34.98) with the bed sheet, and to 7.1mm (95% CI -2.19 to 16.35) with the T-POD.

CONCLUSIONS

Although both a circumferential sheet and the T-POD were able to decrease symphyseal diastasis consistently, only the T-POD showed a statistically significant improvement in diastasis when compared to injury measurements. In 75% of the cadaveric specimens (9 of 12), the T-POD was able to reduce the symphysis to normal (<10mm diastasis). Both a circumferential sheet and the T-POD are effective in provisionally stabilising Burgess and Young anterior-posterior compression II type pelvic injuries, but the T-POD is more effective in reducing symphyseal diastasis.

Imaging in pelvic osteomyelitis: support for early magnetic resonance imaging

BACKGROUND

Children with pelvic osteomyelitis may present with symptoms that are nonspecific. Conventional imaging modalities including plain radiographs, ultrasound, technetium bone scan, and computed tomography rarely demonstrate pathology that is diagnostic of this condition. As a result, accurate diagnosis is often delayed, and children may undergo surgical diagnostic or therapeutic procedures that may be avoided. We report the radiographic and magnetic resonance imaging (MRI) findings in 23 children admitted with a suspected diagnosis of pelvic osteomyelitis. We are presenting imaging findings in children with suspected pelvic osteomyelitis with emphasis on MRI abnormalities and to propose an anatomical classification based on the patterns of pelvic involvement.

METHODS

The medical records and imaging reports of all patients admitted to our institution with a history and physical examination suggestive of pelvic osteomyelitis between July 31, 1992, and March 10, 2003 were reviewed. Criteria were defined for the diagnosis of pelvic osteomyelitis based on criteria used by Farley et al in 1985. Specific attention was paid to the imaging strategies used and the influence of each radiographic method on the ultimate diagnosis.

RESULTS

Abnormalities on the MRI included soft tissue inflammation and bone edema. These findings were bright on T2 and short inversion time Short T1 inversion recovery (STIR) images and enhanced after gadolinium administration. Five distinct patterns of pelvic involvement were observed, each corresponding to a cartilaginous epiphysis or apophysis. These were the sacroiliac joint, triradiate cartilage, pubic symphysis, ischium, and iliac apophysis. One patient had a noninfectious cause of presentation with a deep vein thrombosis, whereas another was diagnosed with Hodgkin lymphoma in addition to osteomyelitis of the ischium.

CONCLUSIONS

Magnetic resonance imaging is a sensitive technique for evaluation of pyogenic infections involving the pelvis. In patients presenting with clinical findings and laboratory studies suggesting an infectious process, MRI with gadolinium enhancement should be performed as an early study. Magnetic resonance imaging is also effective in identifying other conditions that may resemble pelvic osteomyelitis.