Low incidence of vascular uptake during ganglion impar sympathetic nerve blocks for coccydynia.

CONTEXT: Focal sympathetic nerve blocks of the ganglion impar are often effective treatments for coccydynia (coccyx pain) and other pelvic pain syndromes. These injections are generally performed under contrast-enhanced fluoroscopic guidance. Vascular uptake may potentially occur during the injection and vascular uptake rates have been reported for other spinal injections, but never for ganglion impar blocks. AIMS: The purpose of the study was to determine vascular uptake rates during fluoroscopy-guided ganglion impar blocks. SETTINGS AND DESIGN: An academic/University-based Coccyx Pain Center. METHODS AND MATERIALS: A total of 78 consecutive trans-coccygeal ganglion impar blocks were analyzed for vascular uptake of contrast as determined by intermittent fluoroscopy. STATISTICAL ANALYSIS USED: Direct calculation of incidence. RESULTS: Only one patient (1.3%) demonstrated a vascular uptake pattern, which was readily recognized and corrected by slightly adjusting the position of the needle tip and thereby subsequently obtaining the desired contrast pattern at the ganglion impar. CONCLUSIONS: Vascular uptake incidence is low during ganglion impar blocks. This information can be one of the multiple factors considered when a physician is deciding whether or not to use contrast in an individual patient.

An introductory educational session improves medical student knowledge and comfort levels in caring for patients with physical disabilities.

BACKGROUND: Despite a growing number of people living with disabilities (PWD), many experience health disparities related to access to high quality medical care. Lack of knowledge and low comfort level of medical providers in caring for PWD is a significant barrier and can lead to poor health outcomes. Education of future physicians is an important factor in addressing these health disparities. OBJECTIVE/HYPOTHESIS: The objective of this study is to assess the knowledge and comfort level of first-year medical students towards PWD before and after a mandatory educational session focused on the health disparities and appropriate care of PWD. We hypothesized that this introductory session would lead to a greater awareness and improved comfort level around caring for PWD. METHODS: For the two academic years 2016-2018, we created a mandatory educational session for first-year students consisting of a 30-min lecture followed by discussion of video vignettes and a PWD patient panel. Students completed pre- and post-session surveys that evaluated changes in knowledge and comfort levels around working with PWD, and elicited their feedback. RESULTS: 355 students participated in the educational session and among 278 matched pre- and post-survey responses, we found a significant improvement in knowledge and comfort levels towards encountering PWD. Student feedback was overwhelmingly positive with the PWD panel receiving the highest effectiveness rating. CONCLUSION: A mandatory educational session for medical students including didactics, videos, and testimonials on caring for PWD improved students' knowledge and comfort levels. Additional research on the long-term effects of early training is needed.

Sternocleidomastoid Tendinopathy in a Pediatric Athlete.

To our knowledge, this case report describes the first known case of sternocleidomastoid tendinopathy, occurring in a pediatric athlete who had gone undiagnosed for a period of 2 yrs. She presented to our pain clinic with bilateral otalgia, occipital headaches, and occasional bouts of tinnitus and dizziness. An extensive workup by otolaryngology (ENT) including computed tomography imaging of the head, ear pressure equalization, and an attempt at therapeutic tonsillectomy left her with no diagnosis and no symptom relief. A clinical diagnosis of sternocleidomastoid tendinopathy was made at the initial visit based on history and physical examination findings, after excluding other diagnoses. Conservative treatment with physical therapy, acupuncture, and a short course of meloxicam and gabapentin resulted in total symptom resolution. This case is a unique reminder to clinicians that head, neck, and ear pain may precipitate from musculoskeletal origins. It emphasizes the importance of understanding local anatomy, obtaining a thorough history, and performing a detailed physical examination in arriving at an accurate diagnosis.

Responsible, Safe, and Effective Use of Biologics in the Management of Low Back Pain: American Society of Interventional Pain Physicians (ASIPP) Guidelines.

BACKGROUND: Regenerative medicine is a medical subspecialty that seeks to recruit and enhance the body's own inherent healing armamentarium in the treatment of patient pathology. This therapy's intention is to assist in the repair, and to potentially replace or restore damaged tissue through the use of autologous or allogenic biologics. This field is rising like a Phoenix from the ashes of underperforming conventional therapy midst the hopes and high expectations of patients and medical personnel alike. But, because this is a relatively new area of medicine that has yet to substantiate its outcomes, care must be taken in its public presentation and promises as well as in its use. OBJECTIVE: To provide guidance for the responsible, safe, and effective use of biologic therapy in the lumbar spine. To present a template on which to build standardized therapies using biologics. To ground potential administrators of biologics in the knowledge of the current outcome statistics and to stimulate those interested in providing biologic therapy to participate in high quality research that will ultimately promote and further advance this area of medicine. METHODS: The methodology used has included the development of objectives and key questions. A panel of experts from various medical specialties and subspecialties as well as differing regions collaborated in the formation of these guidelines and submitted (if any) their appropriate disclosures of conflicts of interest. Trustworthy standards were employed in the creation of these guidelines. The literature pertaining to regenerative medicine, its effectiveness, and adverse consequences was thoroughly reviewed using a best evidence synthesis of the available literature. The grading for recommendation was provided as described by the Agency for Healthcare Research and Quality (AHRQ). SUMMARY OF EVIDENCE: Lumbar Disc Injections: Based on the available evidence regarding the use of platelet-rich plasma (PRP), including one high-quality randomized controlled trial (RCT), multiple moderate-quality observational studies, a single-arm meta-analysis and evidence from a systematic review, the qualitative evidence has been assessed as Level III (on a scale of Level I through V) using a qualitative modified approach to the grading of evidence based on best-evidence synthesis. Based on the available evidence regarding the use of medicinal signaling/ mesenchymal stem cell (MSCs) with a high-quality RCT, multiple moderate-quality observational studies, a single-arm meta-analysis, and 2 systematic reviews, the qualitative evidence has been assessed as Level III (on a scale of Level I through V) using a qualitative modified approach to the grading of evidence based on best evidence synthesis. Lumbar Epidural Injections Based on one high-quality RCT, multiple relevant moderate-quality observational studies and a single-arm meta-analysis, the qualitative evidence has been assessed as Level IV (on a scale of Level I through V) using a qualitative modified approach to the grading of evidence based on best evidence synthesis. Lumbar Facet Joint Injections Based on one high-quality RCT and 2 moderate-quality observational studies, the qualitative evidence for facet joint injections with PRP has been assessed as Level IV (on a scale of Level I through V) using a qualitative modified approach to the grading of evidence based on best evidence synthesis. Sacroiliac Joint Injection Based on one high-quality RCT, one moderate-quality observational study, and one low-quality case report, the qualitative evidence has been assessed as Level IV (on a scale of Level I through V) using a qualitative modified approach to the grading of evidence based on best evidence synthesis. CONCLUSION: Based on the evidence synthesis summarized above, there is Level III evidence for intradiscal injections of PRP and MSCs, whereas the evidence is considered Level IV for lumbar facet joint, lumbar epidural, and sacroiliac joint injections of PRP, (on a scale of Level I through V) using a qualitative modified approach to the grading of evidence based on best evidence synthesis.Regenerative therapy should be provided to patients following diagnostic evidence of a need for biologic therapy, following a thorough discussion of the patient's needs and expectations, after properly educating the patient on the use and administration of biologics and in full light of the patient's medical history. Regenerative therapy may be provided independently or in conjunction with other modalities of treatment including a structured exercise program, physical therapy, behavioral therapy, and along with the appropriate conventional medical therapy as necessary. Appropriate precautions should be taken into consideration and followed prior to performing biologic therapy. Multiple guidelines from the Food and Drug Administration (FDA), potential limitations in the use of biologic therapy and the appropriate requirements for compliance with the FDA have been detailed in these guidelines. KEY WORDS: Regenerative medicine, platelet-rich plasma, medicinal signaling cells, mesenchymal stem cells, stromal vascular fraction, bone marrow concentrate, chronic low back pain, discogenic pain, facet joint pain, Food and Drug Administration, minimal manipulation, evidence synthesis.

Tailbone Pain from Coccyx Injuries on Water Slides: A Case Series.

BACKGROUND: Water slides and rides are increasingly popular attractions at amusement parks. There has been some documentation of various patterns of injury associated with these rides, most notably vaginal injuries caused by water jets. But we find no previous medical publications reporting the association between water slides/rides with coccydynia (coccyx pain) and tailbone injuries. CASE REPORT: Our purpose in this case report was to assess for an association between water slides/rides with injuries to the coccyx causing coccyx pain. We conducted a retrospective chart review in a coccyx pain clinic on a medical school campus at a level I trauma center. The retrospective chart review took place over a 2-year period and encompassed 217 new patients. Four patients presenting to our coccyx pain clinic had either onset or exacerbation of symptoms with temporal relationship to water slide or ride activities. Three of 4 patients had abnormal dynamic instability on radiologic dynamic imaging, including standing versus seated radiographs and magnetic resonance imaging. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Recreational water slides/rides are a newly reported cause of coccygeal dynamic instability with resultant tailbone pain. Dynamic imaging studies (sitting vs. standing) of the coccyx should be considered in patients with coccyx pain after injuries on a water slide or ride. Many of these patients may initially seek care from emergency physicians.

Coccydynia: Tailbone Pain.

Coccyx (tailbone) pain substantially decreases the quality of life for patients who suffer with this condition. Classic symptoms include midline pain located below the sacrum and above the anus. Symptoms are worse while sitting or during transitions from sitting to standing. Physical examination typically reveals focal tenderness during palpation of the coccyx. Diagnostic tests include radiographs. Advanced studies may include MRI, computerized tomography scans, or nuclear medicine bone scans. Treatments may include the use of cushions, medications by mouth, topical medications, local pain management injections, pelvic floor physical therapy, and (in rare cases) surgical removal of the coccyx (coccygectomy).

Use of Platelet-Rich Plasma in Intra-Articular Knee Injections for Osteoarthritis: A Systematic Review.

OBJECTIVE: To systematically analyze the literature on the use of platelet-rich plasma (PRP) for intra-articular injections of the knee and its efficacy in the treatment of knee osteoarthritis (OA). DESIGN: Systematic literature reviews were conducted in PubMed, Embase, and CINAHL (ie, Cumulative Index to Nursing and Allied Health Literature) on October 30, 2013, using the keywords "platelet-rich plasma" and "knee" and "osteoarthritis." Inclusion criteria included (1) studies with human subjects, (2) prospective clinical studies (including either clinical trials or observational studies), and (3) full-text articles published in English. Exclusion criteria were: (1) animal studies; (2) retrospective studies; (3) patients with previous surgical intervention with total knee arthroplasty or reconstruction of the anterior cruciate ligaments; and (4) articles not published in English RESULTS: A total of 319 abstracts and titles were reviewed (60 from PubMed, 250 from Embase, and 9 from CINAHL). A total of 8 relevant journal articles were identified, all of which were published between 2010 and 2013. One-half of the studies were prospective observational studies that included only PRP treatment; the rest were prospective comparative studies including both PRP and controls-2 were randomized controlled trials. Of the 4 comparative studies, 3 compared PRP with hyaluronic acid, which was considered as a commonly used effective treatment for knee OA; the other one used saline injection (ie, placebo) as the control. Although most of the analyses suffered from small sample size and was thus inconclusive, the findings consistently indicated that PRP might have better outcomes in patients with a lesser degree of degeneration and in younger patients. CONCLUSION: PRP intra-articular injections of the knee may be an effective alternative treatment for knee OA. However, current studies are at best inconclusive regarding the efficacy of the PRP treatment. A large, multicenter randomized trial study is needed to further assess the efficacy of PRP treatment for patients with knee OA.

Musculoskeletal pareidolia in medical education.

BACKGROUND: Medical educators use a variety of strategies to help medical students and resident doctors understand and remember complex topics. METHODS: One teaching tool is matching up radiographic appearances with unrelated, common, non-medical images, in order to help students easily recognise clinical patterns. DISCUSSION: However, even among medical educators who use this approach, many are not aware of the neuropsychiatric phenomenon they are using, known as pareidolia. We will describe pareidolia (a form of patternicity) and give two examples of its use in the clinical teaching of musculoskeletal imaging abnormalities: the winking owl and the Scottie dog.