Superior Cluneal Nerve Entrapment Syndrome: Thought to Be Spondylolysis.

A rare but typically overlooked diagnosis in the orthopaedic surgery community is superior cluneal nerve (SCN) entrapment syndrome. The cluneal nerves function as purely sensory fibers, and the SCNs provide cutaneous innervation to the posterior parasacral, gluteal, and posterolateral thigh regions. When irritated, this syndrome can cause acute and chronic lower back pain and lower extremity symptoms. A 14-year-old adolescent girl presented to the clinic for an evaluation of pain in the right side of her lower back. The patient's physical examination showed tenderness to palpation on the right posterior iliac crest seven centimeters from the midline. Her neurologic examination demonstrated normal deep tendon reflexes, muscle strength, and sensation in the L2-S1 dermatomal distribution. Although imaging showed evidence of a left L5 spondylolysis, she responded positively to a steroid injection over the posterior iliac crest but negatively to one over the L5 pars defect. She later underwent a right SCN decompression surgery. After the procedure, she reported at least 90% improvement in her pain and rated it as a one in severity, on a scale of 0 to 10. Research regarding SCN entrapment syndrome has increased in the past several years. However, most of these studies are limited to the adult population. Therefore, more reports highlighting the potential for this syndrome in adolescents are needed as well.

Repair of large animal partial-thickness cartilage defects through intraarticular injection of matrix-rejuvenated synovium-derived stem cells.

Cartilage defects have a limited ability to self-heal. Stem cell treatment is a promising approach; however, replicative senescence is a challenge to acquiring large-quantity and high-quality stem cells for cartilage regeneration. Synovium-derived stem cells (SDSCs) are a tissue-specific stem cell for cartilage regeneration. Our recent findings suggest that decellularized stem cell matrix (DSCM) can rejuvenate expanded SDSCs in cell proliferation and chondrogenic potential. In this study, we were investigating (1) whether transforming growth factor (TGF)-ß1 and TGF-ß3 played a similar role in chondrogenic induction of SDSCs after expansion on either DSCM or plastic flasks (plastic), and (2) whether DSCM-expanded SDSCs had an enhanced capacity in repairing partial-thickness cartilage defects in a minipig model. SDSCs were isolated from synovium in two 3-month-old pigs and DSCM was prepared using SDSCs. Passage 2 SDSCs were expanded on either DSCM or plastic for one passage. The expanded cells were evaluated for cell morphology, chondrogenic capacity, and related mechanisms. TGF-ß1 and TGF-ß3 were compared for their role in chondrogenesis of SDSCs after expansion on either DSCM or plastic. The chondrogenic induction medium without TGF-ß served as a control. In 13 minipigs, we intraarticularly injected DSCM- or plastic-expanded SDSCs or saline into knee partial-thickness cartilage defects and assessed their repair using histology and immunohistochemistry. We found DSCM-expanded SDSCs were small, had a fibroblast-like shape, and grew quickly in a three-dimensional format with concomitant up-regulation of phosphocyclin D1 and TGF-ß receptor II. Plastic-expanded SDSCs exhibited higher mRNA levels of chondrogenic markers when incubated with TGF-ß3, while DSCM-expanded SDSCs displayed comparable chondrogenic potential when treated with either TGF-ß isotype. In the minipig model, DSCM-expanded SDSCs were better than plastic-expanded SDSCs in enhancing collagen II and sulfated glycosaminoglycan expression in repair of partial-thickness cartilage defects, but both groups were superior to the saline control group. Our observations suggested that DSCM is a promising cell expansion system that can promote cell proliferation and enhance expanded cell chondrogenic potential in vitro and in vivo. Our approach could lead to a tissue-specific cell expansion system providing large-quantity and high-quality stem cells for the treatment of cartilage defects.

Repeated computed tomographic scans in transferred trauma patients: Indications, costs, and radiation exposure.

BACKGROUND: Trauma patients are often transferred to regional Level I trauma centers from other institutions. At times, when the patient presents to the trauma center, radiologic studies performed at the previous institution are repeated. The aim of this study was to assess the proportion of computed tomographic (CT) scans repeated in trauma patients receiving CT scans before transfer and to obtain the indications for these repeats. This study also estimated the additional radiation dose and economic burden associated with repeated CT scans. METHODS: This prospective, observational cohort study collected data consecutively on transferred trauma patients who had received a CT scan at the transferring institution and investigated whether the CT scan was repeated at the receiving institution. Indications for repeating CT scans were obtained from the general surgery trauma service. The economic impacts were assessed using fee schedules from the hospital and the Center of Medicare and Medicaid Services. Effective dose radiation was estimated using the dose-length product method. RESULTS: Of the 211 patients who presented with a previous CT scan at the transferring institution, 82 had at least one repeated CT scan. Indications for repeating CT scans varied based on the body region. Additional hospital charges ranged from $728 to $5,892 with an average of $1,762.40 for patients having one or more repeated CT scans. The estimated additional effective dose radiation ranged from 1.2 mSv to 124 mSv with an average of 21.5 mSv. CONCLUSION: This study reveals the high rates of repeated CT scans in transferred trauma patients and the various indications that lead to them. Additional hospital charges and additional low levels of radiation exposure are a consequence of these repeats. LEVEL OF EVIDENCE: Diagnostic study, level IV.

Investigating racial differences in coping with chronic osteoarthritis pain.

Osteoarthritis is a prevalent disease in older patients of all racial groups, and it is known to cause significant pain and functional disability. Racial differences in how patients cope with the chronic pain of knee or hip osteoarthritis may have implications for utilization of treatment modalities such as joint replacement. Therefore, we examined the relationships between patient race and pain coping strategies (diverting attention, reinterpreting pain, catastrophizing, ignoring sensations, hoping and praying, coping self-statements, and increasing behavior activities) for hip and knee osteoarthritis. This is a cross-sectional survey of 939 veterans 50 to 79 years old with chronic hip or knee osteoarthritis pain recruited from VA primary care clinics in Philadelphia and Pittsburgh. Patients had to have moderate to severe hip or knee osteoarthritis symptoms as measured by the WOMAC index. Standard, validated instruments were used to obtain information on attitudes and use of prayer, pain coping strategies, and arthritis self-efficacy. Analysis included separate multivariable models adjusting for demographic and clinical characteristics. Attitudes on prayer differed, with African Americans being more likely to perceive prayer as helpful (adjusted OR = 3.38, 95% CI 2.35 to 4.86) and to have tried prayer (adjusted OR = 2.28, 95% 1.66 to 3.13) to manage their osteoarthritis pain. Upon evaluating the coping strategies, we found that, compared to whites, African Americans had greater use of the hoping and praying method (beta = 0.74, 95% CI 0.50 to 0.99). Race was not associated with arthritis pain self-efficacy, arthritis function self-efficacy, or any other coping strategies. This increased use of the hoping and praying coping strategy by African Americans may play a role in the decreased utilization of total joint arthroplasty among African Americans compared to whites. Further investigation of the role this coping strategy has on the decision making process for total joint arthroplasty should be explored.