A Retrospective Review of Spinal Radiofrequency Neurotomy Procedures in Patients with Metallic Posterior Spinal Instrumentation - Is it Safe?

BACKGROUND: Recent studies have shown that medial branch radiofrequency neurotomy (RFN) procedures done at the level of a pedicle screw can increase pedicle screw temperature, and it has been speculated that pedicle screw heating may cause thermal injury. There has been a limited amount of investigation into the real-world safety profile of RFN procedures in patients with pedicle screws. OBJECTIVES: We aim to demonstrate that the occurrence of serious adverse events is rare for a medial branch RFN procedure completed at a level with metallic spinal hardware when performed according to the Spine Intervention Society practice standards. STUDY DESIGN: This study involved retrospective chart reviews of every patient who received an RFN procedure for spinal facet joint pain during the 5-year time period from 2012-2016. SETTING: The research took place within a single university-based interventional pain management center. METHODS: The study sample included 507 patient charts. Data collection included patient demographics, RF denervation sites at a level with metallic hardware, and all serious RF-related complications that could be attributable to heated metallic hardware. The research team developed medical-chart abstraction criteria for each of the following categorized complications: a) superficial burns, b) deep burns, c) denervation of dorsal ramus, d) denervation of ventral ramus, and e) coagulation of a spinal vascular structure. RESULTS: Of the 36 patients who met the inclusion criteria for this study, 43.6% were men and 56.4% were women. The mean age was 59.5 years old, with an age range of 25 to 87 years. There were a total of 56 ablations performed at a level with metallic spinal hardware, of which 11 were cervical, 44 were lumbar, and 1 was thoracic . There were zero documented complications found among our patient population in any of the 5 categories of serious complications. LIMITATIONS: As a retrospective chart review, this study was dependent on the availability and accuracy of medical records. Chart abstraction criteria for each outcome measure were developed by the research team without scientific testing. CONCLUSIONS: There have been no reported complications attributable to hardware temperature increases when performing medial branch RFNs at the level of a pedicle screw. For safety, it is important to use multiplanar fluoroscopic imaging techniques to ensure that the RFN cannula is not in contact with the pedicle screw. KEY WORDS: Radiofrequency neurotomy, medial branch nerve ablation, safety, thermal injuries, metallic spinal hardware, pedicle screws, lateral mass screws, cervical facet joints, severe complications, adverse events.

Tibialis Posterior Tenosynovitis: A Unique Musculoskeletal Manifestation of Gout.

Extra-articular manifestations of gout can present in several ways, including tenosynovitis. We present a rare case of acute tibialis posterior gouty tenosynovitis. An 82-year-old man with a history of well-controlled gout presented with acute onset of left ankle pain, occurring without inciting event. The medial ankle was slightly erythematous with moderate dorsal-medial swelling and mild dorsal-lateral swelling, with severe tenderness to palpation over the medial retro-malleolar region. Range of motion and manual muscle testing were pain limited throughout. Ultrasound examination revealed a left posterior tibialis tendon sheath tenosynovitis with effusion and overlying soft tissue edema. Tendon sheath aspirate revealed sodium urate crystals and a white blood cell count of 6400/µL. Tendon sheath injection with a mixture of 1% lidocaine and dexamethasone 4 mg resulted in symptom resolution. Repeat ultrasound examination demonstrated no evidence of tibialis posterior tendon sheath effusion. This case is unique not only because acute gouty posterior tibialis tenosynovitis is very rare, particularly in a normouricemic individual, but also because the sonographic evidence of gouty infiltration into the posterior tibialis tendon and overlying subcutaneous tissue considerably aided in arriving at the correct diagnosis in a timely manner.

Fetal and neonatal exposure to the endocrine disruptor, methoxychlor, reduces lean body mass and bone mineral density and increases cortical porosity.

Endogenous estrogen has beneficial effects on mature bone and negatively affects the developing skeleton, whereas the effect of environmental estrogens is not known. Methoxychlor (MXC) is a synthetic estrogen known as a persistent organochlorine and used as a pesticide. Methoxychlor and its metabolites display estrogenic, anti-estrogenic and anti-androgenic activity and may therefore influence bone. Fifty-eight male fetal and neonatal rats were exposed to either: a negative control (DMSO), 0.020, 100 mg/kg MXC, or 1 mg/kg ß-estradiol-3-benzoate (EB; positive control). Rats were treated daily for 11 days, from embryonic day 19 to postnatal day (PND) 7 or for 4 days during the postnatal period (PND 0-7). All rats were analyzed at PND-84. Total body, femur, spine, and tibia areal bone mineral density (BMD) and content (BMC), lean body mass (LBM) and fat were measured by dual energy X-ray absorptiometry. Bone geometry and volumetric (v) BMD were measured using micro-computed tomography and biomechanical properties using three-point bending were assessed. Rats exposed to EB or MXC (at either the high and/or low dose), independent of exposure interval showed lower body weight, LBM, tibia and femur BMD and length, and total body BMD and BMC than DMSO control group (p ≤ 0.05). Methoxychlor and EB exposure increased cortical porosity compared to DMSO controls. Trabecular vBMD, number and separation, and cortical polar moment of inertia and cross-sectional area were lower due to EB exposure compared to control (p < 0.05). Early MXC exposure compromises cortical porosity and bone size at maturity, and could ultimately increase the risk of fracture with aging.

Coccyx fractures treated with intranasal calcitonin.

BACKGROUND: Treating pain associated with acute coccyx fractures can be challenging. Intranasal calcitonin has been used to treat acute pain after vertebral fracture, and may even accelerate fracture healing. However, intranasal calcitonin has never previously been published as part of the treatment of acute coccyx fractures. OBJECTIVE: To examine a series of cases in which intranasal calcitonin was used to treat coccydynia related to coccyx fractures. STUDY DESIGN: Case series and literature review. SETTING: Outpatient university-based coccyx pain center. RESULTS: After use of intranasal calcitonin, pain levels decreased, adverse events were minimal, and the medication was generally well tolerated. LIMITATIONS: As this is not a randomized control trial, the patients treated with intranasal calcitonin were not compared to a control group. Additionally, the sample size of 8 patients is relatively small. CONCLUSIONS: We propose that clinicians consider use of intranasal calcitonin for the treatment of pain due to acute coccyx fractures.

Evaluation of contact precautions discharges in an acute care setting.

The health care environment is increasingly discussed as a source of health care-associated infections. We evaluated patterns of discharges among patients on contact precautions (CP) and assessed correlation of CP discharges with health care acquisition of organisms requiring CP and evaluated the feasibility of targeting CP discharges for additional monitoring.