Isolated Nerve Palsy of the Flexor Pollicis Longus After a Radial Shaft Fracture: A Case Report.

We present the case of a patient who developed an isolated palsy of the flexor pollicis longus (FPL) branch of the anterior interosseous nerve (AIN) following a fracture of the right radial shaft. The diagnosis of AIN palsy in this setting is rare, especially involving partial neuropathies of only the FPL branch. Clinical presentation in this scenario can be mistaken for other musculoskeletal pathology, and electrodiagnostic studies can be helpful in confirming the diagnosis.

The PROMIS Upper Extremity Computer Adaptive Test Correlates With Previously Validated Metrics in Patients With Carpal Tunnel Syndrome.

Background: The Patient-Reported Outcomes Measurement Information System Upper Extremity (PROMIS UE) computer adaptive test was developed to improve precision and reduce question burden. We hypothesized that in patients with carpal tunnel syndrome (CTS): (1) PROMIS UE would correlate with established patient-reported outcome measures (PROs); (2) the time and number of questions required would be lower than current metrics; (3) there would be no floor or ceiling effects; and (4) PROMIS UE would not correlate with disease severity. Methods: Patients undergoing electrodiagnostic evaluation found to have a primary diagnosis of unilateral CTS prospectively completed PROMIS UE, Quick Disabilities of the Arm, Shoulder and Hand (qDASH), and Boston Carpal Tunnel Syndrome Questionnaire (BCTQ). Electrophysiologic and clinical severity was recorded. The relationships among PROs were described with Spearman coefficients. A floor or ceiling effect was confirmed if >15% of patients achieved the lowest or highest possible score, respectively. Results: Fifty-one patients (average, 53.9 years) were enrolled. An excellent correlation was identified between PROMIS UE and qDASH (R = -0.76, P < .001). There was a good correlation between PROMIS UE and BCTQ (R = -0.58, P < 0.001). The PROMIS UE required less time and fewer questions than qDASH and BCTQ (P = .02 and P < .001). There were no floor or ceiling effects. Neither neurophysiologic nor clinical severity correlated with PROMIS UE (R = 0.24, P > .05 and R = -0.18, P > .05). Conclusions: The PROMIS UE has an excellent correlation with qDASH and a good correlation with BCTQ in patients with CTS. Furthermore, PROMIS UE required less time and fewer questions than established PROs. Used as a single PRO, PROMIS UE represents a practical alternative to current metrics in patients with CTS.

Predicting outcomes of total joint arthroplasty using the distress and risk assessment method.

BACKGROUND: Psychological distress is presumed to be an important factor that can adversely impact the outcome of orthopaedic procedures. The Distress and Risk Assessment Method (DRAM) is an evaluation tool which assesses psychological distress in patients with low back pain. The purpose of this prospective study was to assess the influence of preoperative psychological distress, as determined by the DRAM score, on the functional outcomes of total joint arthroplasty (TJA). MATERIALS AND METHODS: A prospective study of 61 TJAs was performed at a single institution. The DRAM questionnaire and a variety of functional measures (12-Item Short Form Health Survey [SF-12], visual analogue scale [VAS], Oxford Hip Score [OHS], Oxford Knee Score [OKS], and Oswestry Disability Questionnaire [ODQ]) were administered to the patient at baseline, 1 month, and 6 months postoperatively. Mixed model regressions and Mann-Whitney tests were utilised to evaluate the relationship of the DRAM score with functional outcomes. RESULTS: The summed quantitative DRAM score was predictive of functional outcomes. With each 1 point increase in psychological distress, VAS pain increased by 0.023 (p = 0.015), OKS decreased by 0.34 (p = 0.01), ODQ increased by 0.065 (p = 0.02), and MCS decreased by 0.14 (p = 0.015). In addition, patients with lower preoperative distress scores had higher rates of improvement than patients with higher preoperative distress scores for VAS pain (p = 0.034). DISCUSSION: Psychological distress was associated with decreased baseline mental health and function in the early postoperative period, which has important implications for bundled payments. However, patients with psychological distress still demonstrated functional improvements and TJA should thus not be contraindicated in these patients.

Persistent knee pain after uncomplicated total knee arthroplasty secondary to undiagnosed spondylotic myelopathy: a case report.

Introduction: Knee osteoarthritis and cervical spondylotic myelopathy are both frequent disorders in the aging patient. Total knee arthroplasty is an increasingly common surgical procedure, with approximately 20% of patients describing persistent knee pain after the procedure, for which it is often difficult to find a cause. We review known reasons for pain after total knee arthroplasty and present a new clinically challenging case of persistent knee pain due to previously undiagnosed cervical spondylotic myelopathy. Case presentation: Our patient presented with painful knee spasms after an uncomplicated total knee arthroplasty. Her workup revealed cervical spondylotic myelopathy with isolated changes in tone in the affected extremity as well as weakness and atrophy in non-painful limbs. Her clinical status improved after cervical decompression and fusion. We perform a literature review for prior reports of isolated knee pain due to cervical spondylotic myelopathy and find no previous reported association with total knee arthroplasty. Discussion: Cervical spondylotic myelopathy is the most common spinal cord disorder in older adults. Incidence increases with age and the clinical manifestations may present with a variety of neurological findings. Careful musculoskeletal and neurologic examination is critical to an accurate and timely diagnosis.

Neer Award 2018: the effect of preoperative education on opioid consumption in patients undergoing arthroscopic rotator cuff repair: a prospective, randomized clinical trial.

BACKGROUND: Opioids are commonly administered for the treatment of acute and chronic pain symptoms. The current health care system is struggling to deal with increasing medication abuse and rising mortality rates from overdose. Preoperative patient-targeted education on opioid use is an avenue yet to be explored. The purpose of the study was to determine whether preoperative narcotics education reduces consumption after arthroscopic rotator cuff repair (ARCR). METHODS: Patients undergoing primary ARCR at our institution were randomized to receiving opioid-related preoperative education or not. Patients filled out preoperative questionnaires detailing complete medical history and visual analog scale (VAS) for pain. Patients completed questionnaires regarding their opioid consumption and pain at their 2-week, 6-week, and 3-month follow-up. RESULTS: The study enrolled 140 patients. Patients in the study group consumed significantly less narcotics than the control group at the 3-month follow-up. Patients in the education group were 2.2 times more likely to discontinue narcotic use by the end of follow-up (odds ratio, 2.19; P = .03). In addition, patients with a history of preoperative narcotic use that were in the education group were 6.8 times more likely to discontinue narcotics by the end of follow-up (odds ratio, 6.8; P = .008). DISCUSSION/CONCLUSIONS: The findings of this study determined that preoperative education intervention significantly decreased the number of narcotic pills consumed at 3 months after ARCR. In addition, education resulted in earlier cessation of opioids; therefore, directed patient education can help alleviate the current opioid epidemic.

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

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

Comparative Effectiveness of Treatments for Chronic Low Back Pain: A Multiple Treatment Comparison Analysis.

STUDY DESIGN: A systematic review and network meta-analysis. OBJECTIVE: To determine current treatment options of chronic low back pain (LBP) as defined by randomized controlled trials (RCTs) and to compare effectiveness of those treatments using a mixed-treatment comparison (MTC). SUMMARY OF BACKGROUND DATA: It is important to provide an evidence-based assessment of the treatment options that exist for LBP. METHODS: A systematic search of RCTs was conducted in MEDLINE and the Cochrane Collaboration Library from 1990 to 2014. From the selected studies, we extracted preoperative and postoperative ODI and VAS back pain scores, additional surgeries, and complications. Standard and network meta-analytic techniques were used. RESULTS: Twelve RCTs were included in the analysis: 5 total disk replacement (TDR) versus fusion; 1 TDR versus exercise and cognitive behavioral therapy (CBT); 5 fusion versus exercise and CBT; and 1 fusion versus physical therapy (PT). On the basis of MTC, with respect to ODI change scores, the pooled mean difference favoring fusion over exercise and CBT was 2.0 points (95% CI, -1.2 to 4.8). The pooled mean difference favoring TDR over exercise and CBT was 6.4 points (95% CI, 3.2-9.3). The pooled mean difference favoring fusion over PT was 8.8 points (95% CI, 4.1-13.6). The pooled mean differences favoring TDR over fusion was 4.4 points (95% CI, 2.37-6.63). For PT versus structured exercise with CBT, the pooled mean difference favoring exercise with CBT over PT was 6.8 points (95% CI, 1.5-12.8). For TDR versus PT, the pooled mean difference favoring TDR over PT was 13.2 points (95% CI, 8.0-18.4). Additional surgery rates were similar between treatment options. CONCLUSIONS: All 4 treatments provided some benefit to patients with chronic LBP. According to the MTC analysis, TDR may be the most effective treatment and PT the least effective treatment for chronic LBP. This review is based on a limited number of RCT studies and does not support any 1 treatment modality for all patients.

Complex regional pain syndrome: diagnosis and treatment.

This article discusses the diagnostic criteria, clinical course, and complications of complex regional pain syndrome. Multidisciplinary treatment including physical and occupational therapy, psychological evaluation and treatment, pharmacologic management, and more aggressive options including sympathetic blocks, sympathectomy, and spinal cord stimulation are also reviewed.

Does opioid pain medication use affect the outcome of patients with lumbar disc herniation?

STUDY DESIGN: Subgroup analysis of prospective, randomized cohort. OBJECTIVE: To review the results of patients who received opioid pain medications during treatment compared with that of patients who did not receive opioid medications. SUMMARY OF BACKGROUND DATA: The Spine Patient Outcomes Research Trial (SPORT) is a prospective, multicenter study of surgical treatment versus nonoperative treatment for lumbar intervertebral disc herniation. METHODS: The study population includes patients enrolled in SPORT for treatment of intervertebral disc herniation in combined randomized and observational cohorts. Patients who received opioid medications at baseline (opioid) were compared with those who did not (nonopioid). RESULTS: There were 520 patients in the nonopioid group and 542 patients in the opioid group. Among the opioid medication group, there were significantly (P < 0.001) worse baseline scores in primary and secondary outcome measures. There was an increased percentage of patients in the opioid medication group with the perception of worsening symptoms and neurological deficit (P < 0.001). A higher percentage of the opioid group patients received surgery (P < 0.001).At 4 years of follow-up, there were no significant differences in primary or secondary outcome measures or treatment effect of surgery between opioid and nonopioid medication group patients. Opioid medications were associated with increased crossover to surgical treatment (P = 0.005) and decreased surgical avoidance (P = 0.01). The incidence of opioid use at 4 years was 16% among patients who were using opioids at baseline and 5% among patients who were not using opioids at baseline. CONCLUSION: Patients who were treated with opioids had significantly worse baseline pain and quality of life. At final follow-up, there was no long-term difference in outcome associated with opioid pain medication use. Opioid medications were not associated with surgical avoidance. The majority of patients who use opioids during the study did not continue usage at 4 years. LEVEL OF EVIDENCE: 2.

Update on the role of z-joint injection and radiofrequency neurotomy for cervicogenic headache.

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

Electrodiagnostic evaluation of compressive nerve injuries of the upper extremities.

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

The impact of diabetes on the outcomes of surgical and nonsurgical treatment of patients in the spine patient outcomes research trial.

STUDY DESIGN: A secondary analysis comparing diabetic patients with nondiabetic patients enrolled in the Spine Patient Outcomes Research Trial (SPORT). OBJECTIVE: To compare surgical outcomes and complications between diabetic and nondiabetic spine patients. SUMMARY OF BACKGROUND DATA: Patients with diabetes are predisposed to comorbidities that may confound the diagnosis and treatment of patients with spinal disorders. METHODS: Baseline characteristics and outcomes of 199 patients with diabetes were compared with those of the nondiabetic population in a total of 2405 patients enrolled in the Spine Patient Outcomes Research Trial for the diagnoses of intervertebral disc herniation (IDH), spinal stenosis (SpS), and degenerative spondylolisthesis (DS). Primary outcome measures include the 36-Item Short Form Health Survey (SF-36) Health Status questionnaire and the Oswestry Disability Index. RESULTS: Patients with diabetes were significantly older and had a higher body mass index than nondiabetic patients. Comorbidities, including hypertension, stroke, cardiovascular disease, and joint disease, were significantly more frequent in diabetic patients than in nondiabetic patients. Patients with diabetes and IDH did not make significant gains in pain and function with surgical intervention relative to diabetic patients who underwent nonoperative treatment. Diabetic patients with SpS and DS experienced significantly greater improvements in pain and function with surgical intervention when compared with nonoperative treatment. Among those who had surgery, nondiabetic patients with SpS achieved marginally significantly greater gains in function than their diabetic counterparts (SF-36 physical function, P = 0.062). Among patients who had surgery for DS, diabetic patients did not have as much improvement in pain or function as did the nondiabetic population (SF-36 bodily pain, P = 0.003; physical function, P = 0.002). Postoperative complications were more prevalent in patients with diabetes than in nondiabetic patients with SpS (P = 0.002). There was an increase in postoperative (P = 0.028) and intraoperative (P = 0.029) blood replacement in DS patients with diabetes. CONCLUSION: Diabetic patients with SpS and DS benefited from surgery, though older SpS patients with diabetes have more postoperative complications. IDH patients with diabetes did not benefit from surgical intervention.

Biological treatment for degenerative disc disease: implications for the field of physical medicine and rehabilitation.

Spine care is a fast-growing sector of the outpatient practice for physiatrists. Current nonsurgical treatment modalities and surgical options for severe symptomatic intervertebral disc degeneration have limited and inconsistent clinical results. Thus, the development of novel approaches, such as biological treatments that offer the potential to halt or even reverse disc degeneration and restore physiologic disc function, are very attractive. In this article, we first review the structural changes that occur during intervertebral disc degeneration and their relationship with discogenic back pain. Subsequently, we review the treatment approaches currently under clinical trial and laboratory investigation. Physiatrists specializing in spine care have the skill set required for administering intradiscal injections and supervising a comprehensive rehabilitation program after the procedures. Ultimately, the clinical use of any biological treatment discussed herein would require the collective efforts of physicians (such as physiatrists and surgeons) and researchers (such as chemical and biomedical engineers, biologists, and chemists).

Interventions in chronic pain management. 1. Update on important definitions in pain management.

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

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

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

Interventions in chronic pain management. 3. Evaluation and management of lumbar pain syndromes.

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

Interventions in chronic pain management. 4. Monitoring progress and compliance in chronic pain management.

UNLABELLED: This self-directed learning module highlights the monitoring of progress and compliance in chronic pain management. It is part of the chapter on chronic pain in the Self-Directed Physiatric Education Program for practitioners in physical medicine and rehabilitation. Specifically, the first module focuses on the use of pain rating scales to monitor progress, and the second and third learning objectives focus on evaluating abuse potential and interpreting drug screens. The fourth objective discusses issues pertaining to closure of a workers' compensation complaint, including when to declare that a patient meets the requirements for the designation maximal medical improvement. OVERALL ARTICLE OBJECTIVE: To discuss monitoring of a patient's progress and compliance by describing how pain rating scales are used, what screening procedures are available to help identify patients at risk for drug abuse, and what the basis is for declaring a patient as having reached maximal medical improvement.

Interventions in chronic pain management. 5. Approaches to medication and lifestyle in chronic pain syndromes.

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

Interventions in chronic pain management. 6. Interventional approaches to chronic pain management.

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