A Novel Ultrasound-Guided Bilateral Vagal Nerve Hydrodissection With 5% Dextrose Without Local Anesthetic for Recalcitrant Chronic Multisite Pain and Autonomic Dysfunction.

Chronic pain is a complex condition that often poses diagnostic and management challenges due to its multifactorial etiology. This case report describes a 49-year-old pastor who presented with a three-year history of chronic pain affecting multiple sites, including the neck, bilateral shoulders, thoracic region, lower back, and bilateral knees. Additionally, he experienced shortness of breath on mild exertion, which adversely affected his ability to converse and speak publicly. The patient had a rapid resting heart rate of 100-120 beats per minute, occasional palpitations, and a 24-hour electrocardiogram that confirmed 15% premature ventricular complexes with bigeminy and trigeminy. He complained of limited appetite with early satiety, intermittent nausea, and regurgitation. Despite consultations with multiple specialists, no underlying causes were identified in the cardiac, respiratory, gastrointestinal, or psychological domains. Ultrasound-guided bilateral vagus nerve hydrodissection using 5% dextrose without local anesthetics was administered three times at monthly intervals, resulting in remarkable pain relief within three months and the effects persisted at the nine-month follow-up. Tachycardia was no longer perceived, resting heart rate slowed to 70-80 beats per minute, shortness of breath improved, and public speaking ability was restored. The patient's early satiety, nausea, and reflux complaints were resolved. This case report highlights the potential effectiveness of this novel intervention for chronic pain. Further research is warranted to validate these findings and explore the mechanism of action.

Ultrasound Evaluation and Guided Injection of the Subscapularis and Serratus Anterior Muscles Between the Scapula and the Thoracic Cage: A Technical Note.

Most subscapularis and serratus anterior muscles lie between the scapula and the thoracic cage. Evaluation of this area in patients with scapulothoracic dyskinesis, snapping scapular syndrome, or interscapular pain can provide valuable information to clinicians. However, ultrasound scanning of pathologies in this area is hindered by anatomical limitations. In this study, we described a simple patient setup position and scanning method for ultrasound evaluation and guided intervention of the subscapularis and serratus anterior muscles between the scapula and thoracic cage.

Pictorial Essay on Ultrasound and Magnetic Resonance Imaging of Paraspinal Muscles for Myofascial Pain Syndrome.

The paraspinal muscles of the cervical, thoracic, and lumbar spine are important pain generators because muscle strains or myofascial pain syndrome caused by trigger points are common during clinical practice. Ultrasonography is the most convenient imaging tool for evaluating these muscles due to its advantages, such as providing good delineation of soft tissues, easy accessibility, and zero radiation. Additionally, ultrasound can serve as a useful guiding tool for paraspinal muscle intervention to prevent inadvertent injuries to vital axial neurovascular structures. This pictorial essay presents ultrasound scanning protocols for the paraspinal and other associated muscles as well as a discussion of their clinical relevance. Axial magnetic resonance imaging has also been used to elucidate reciprocal anatomy. In conclusion, ultrasound imaging proves to be a valuable tool that facilitates the differentiation of individual paraspinal muscles. This capability significantly enhances the precision of interventions designed to address myofascial pain syndrome.

Ultrasound imaging of the posterior lateral corner of the knee: a pictorial review of anatomy and pathologies.

Assessment of the posterior lateral knee pain poses diagnostic challenges, requiring accurate evaluation of various structures in light of the medical history and physical examination. Despite substantial progress in the ultrasonographic diagnosis of musculoskeletal disorders, the current protocol (EURO-MUSCULUS/USPRM. Basic scanning protocols for knee) fails to conduct a comprehensive investigation into the intricate, tendons, and ligaments of the posterior lateral knee. This pictorial review aims to bridge this gap by offering a systematic approach to utilize ultrasound examination of the less-discussed structures in this specific region. Providing cadaveric and magnetic resonance images, this essay demonstrates the efficacy of ultrasound in diagnosing posterior lateral knee pain. Notably, pathologies such as ligamentous sprains and tears are clearly discernible. Moreover, the integration of ultrasound guidance plays a vital role in reducing the risk of inadvertent neurovascular injury during injection, such as the common peroneal nerve and lateral genicular artery. This comprehensive approach will enhance clinicians' understanding and equip them with effective management strategies for posterior lateral knee pain.Critical relevance statement In this visual exposition, we delve into the intricacies of the posterior lateral corner of the knee. Offering a methodical approach to employ ultrasound for visualization of the less-explored structures within this region, the authors aim to enhance the diagnosis in posterior lateral knee pain.Key points1. Ultrasound excels at revealing intricate structures in the posterior lateral knee.2. Due to proximity of vital structures, extreme caution is crucial during injections.3. Employing dynamic scan and understanding ligaments enables a comprehensive exploration of pathologies.

Infraspinatus Fascial Dysfunction as a Cause of Painful Anterior Shoulder Snapping: Its Visualization via Dynamic Ultrasound and Its Resolution via Diagnostic Ultrasound-Guided Injection.

This report presents the first case of painful anterior shoulder snapping due to a thickened, fibrotic bursa snapping between the subscapularis and the short head of the bicep during external and internal rotation of the humerus. A 46-year-old presented with a 10-month history of on-and-off anterolateral right shoulder pain and snapping. Direct treatment to the anterior suspected lesions partially and temporarily relieved the pain but did not reduce the snapping. Further musculoskeletal examination and dynamic ultrasound scanning showed dysfunction in the scapulothoracic movement and defects of the muscles that interact with the infraspinatus aponeurotic fascia. An ultrasound-guided diagnostic injection to the suspected lesions in the infraspinatus fascia and its muscles attachments improved the scapulothoracic movement, and the snapping and pain were eliminated immediately after the injection, which further shows that the defects in the infraspinatus fascia may be the root cause of the painful anterolateral snapping. The importance of the infraspinatus fascia and its related muscle in maintaining the harmony of the scapulothoracic movement and flexibility of the shoulder is considerable.

Efficacy of 5% Dextrose Water Injection for Peripheral Entrapment Neuropathy: A Narrative Review.

Current non-surgical treatment for peripheral entrapment neuropathy is considered insignificant and unsustainable; thus, it is essential to find an alternative novel treatment. The technique of perineural injection therapy using 5% dextrose water has been progressively used to treat many peripheral entrapment neuropathies and has been proven to have outstanding effects in a few high-quality studies. Currently, the twentieth edition of Harrison's Principles of Internal Medicine textbook recommends this novel injection therapy as an alternative local treatment for carpal tunnel syndrome (CTS). Hence, this novel approach has become the mainstream method for treating CTS, and other studies have revealed its clinical benefit for other peripheral entrapment neuropathies. In this narrative review, we aimed to provide an insight into this treatment method and summarize the current studies on cases of peripheral entrapment neuropathy treated by this method.

Spontaneous Conversion of Lamellar Macular Holes to Full-Thickness Macular Holes: Clinical Features and Surgical Outcomes.

PURPOSE: To describe the clinical features and surgical outcomes of patients experiencing a spontaneous conversion of a lamellar macular hole (LMH) to a full-thickness macular hole (FTMH). DESIGN: Retrospective, multicenter, observational case series. PARTICIPANTS: Patients with LMH who experienced a spontaneous conversion to FTMH and underwent FTMH surgery. METHODS: Clinical charts and OCT features of 20 eyes of 20 patients were reviewed. MAIN OUTCOME MEASURES: OCT features and surgical outcomes of FTMH derived from LMH. RESULTS: The mean baseline visual acuity (VA) was 0.21 ± 0.19 logarithm of the minimum angle of resolution (logMAR) (20/32 Snellen equivalent [SE]). Epiretinal proliferation was noted in 18 eyes (90%), and 14 eyes (75%) had an epiretinal membrane. At the diagnosis of FTMH, the mean VA decreased to 0.61 ± 0.50 logMAR (20/81 SE) (P = 0.001). The mean FTMH diameter was 224.4 ± 194.8 µm, with 15 (75%) small (≤250 µm), 2 (10%) medium (>250-≤400 µm), and 3 (15%) large (>400 µm) FTMHs. Eighteen (90%) FTMHs were sealed after 1 surgery, and 2 (10%) required an additional procedure. At the last follow-up, the mean VA was increased to 0.29 ± 0.23 logMAR (20/38 SE) (P = 0.003), but did not significantly differ from the baseline VA (P = 0.071). CONCLUSIONS: Patients with LMH may develop an FTMH with no evidence of vitreomacular traction. A tangential traction from an epiretinal membrane may contribute to its genesis, but a progressive loss of retinal tissue and an inherent weakness of the foveal architecture in LMH eyes could be sufficient. Most FTMHs derived from LMH had a small diameter, showed epiretinal proliferation, showed limited retinal hydration, and were associated with relatively poor surgical outcomes compared with idiopathic FTMH.

The current perspective of the PA 1957 gas well pillar study and its implications for longwall gas well pillars.

Many states rely upon the Pennsylvania 1957 Gas Well Pillar Study to evaluate the coal barrier surrounding gas wells. The study included 77 gas well failure cases that occurred in the Pittsburgh and Freeport coal seams over a 25-year span. At the time, coal was mined using the room-and-pillar mining method with full or partial pillar recovery, and square or rectangle pillars surrounding the gas wells were left to protect the wells. The study provided guidelines for pillar sizes under different overburden depths up to 213 m (700 ft). The 1957 study has also been used to determine gas well pillar sizes in longwall mines since longwall mining began in the 1970 s. The original study was developed for room-and-pillar mining and could be applied to gas wells in longwall chain pillars under shallow cover. However, under deep cover, severe deformations in gas wells have occurred in longwall chain pillars. Presently, with a better understanding of coal pillar mechanics, new insight into subsidence movements induced by retreat mining, and advances in numerical modeling, it has become both critically important and feasible to evaluate the adequacy of the 1957 study for longwall gas well pillars. In this paper, the data from the 1957 study is analyzed from a new perspective by considering various factors, including overburden depth, failure location, failure time, pillar safety factor (SF), and floor pressure. The pillar SF and floor pressure are calculated by considering abutment pressure induced by full pillar recovery. A statistical analysis is performed to find correlations between various factors and helps identify the most significant factors for the stability of gas wells influenced by retreat mining. Through analyzing the data from the 1957 study, the guidelines for gas well pillars in the 1957 study are evaluated for their adequacy for room-and-pillar mining and their applicability to longwall mining. Numerical modeling is used to model the stability of gas wells by quantifying the mining-induced stresses in gas well casings. Results of this study indicate that the guidelines in the 1957 study may be appropriate for pillars protecting conventional gas wells in both room-and-pillar mining and longwall mining under overburden depths up to 213 m (700 ft), but may not be sufficient for protective pillars under deep cover. The current evaluation of the 1957 study provides not only insights about potential gas well failures caused by retreat mining but also implications for what critical considerations should be taken into account to protect gas wells in longwall mining.

Long term outcomes for patients with von Hippel-Lindau and Pheochromocytoma: defining the role of active surveillance.

INTRODUCTION: Patients with a confirmed germline mutation in the von Hippel-Lindau (VHL) tumor suppressor gene have been followed at the National Cancer Institute since the 1980s. In this study, we identify VHL patients with pheochromocytoma and long-term follow-up to determine the best candidates for active surveillance and surgical resection. METHODS: A prospectively collected database of patients with a confirmed germline VHL mutation was reviewed to identify patients with a history of pheochromocytoma and at least 10 years of follow up. The presence of symptoms was assessed at the time of resection. Imaging data obtained at each clinic visit was reviewed to evaluate mass size and annual growth rate. Catecholamine data were reviewed to evaluate for data above the upper limit of the reference range. Masses that underwent imaging at least 3 months apart were considered in our surveillance cohort. RESULTS: Median follow up was 16.7 years. There was a size-dependent increase in catecholamine production (P<0.05). For 36 masses on active surveillance, growth rate increased exponentially from 0.03 cm/y when masses were <1 cm to 0.32 cm/y when masses were greater than 2 cm. Approximately 1/3 of patients developed another pheochromocytoma after initial resection with a median time of 7.9 years. Partial adrenalectomy was associated with no metastatic events and a steroid-free rate of 97%. CONCLUSION: Active surveillance is a safe strategy for management of VHL associated pheochromocytoma in masses less than 2 cm.

The Timing of Large Submacular Hemorrhage Secondary to Age-Related Macular Degeneration Relative to Anti-VEGF Therapy.

PURPOSE: To characterize the timing of large submacular hemorrhage (SMH) secondary to neovascular age-related macular degeneration (AMD) relative to anti-vascular endothelial growth factor (VEGF) therapy. DESIGN: Retrospective, consecutive case series. PARTICIPANTS: The study included 46 eyes of 46 patients with large SMH resulting from neovascular AMD selected to undergo pars plana vitrectomy with subretinal tissue plasminogen activator at the Mid Atlantic Retina group of the Wills Eye Hospital. METHODS: Patient charts were reviewed to identify baseline characteristics and anti-VEGF treatment details. OCT was used to evaluate pigmented epithelial detachments, SMH, and subretinal fluid before and after SMH. MAIN OUTCOME MEASURES: The timing of SMH in relation to last anti-VEGF injection, the anti-VEGF treatment status (i.e., naive, stable, or recently extended or shortened) at the time of SMH, and the length of the anti-VEGF treatment interval at the time of bleeding. RESULTS: Submacular hemorrhage occurred in 15 patients (36%) who were treatment naive. In patients treated with anti-VEGF, 19 (45%) had a stable treatment interval, 5 (12%) had a recently extended interval, and 3 (7%) had a shortened interval. The average treatment interval at the time of SMH was 6.8 weeks with a median of 7 total injections before SMH. Seven treated patients (26%) experience an SMH while having a 4-week dosing interval. The average time between last injection and SMH was 29 days. Forty-eight percent of patients treated with anti-VEGF agents experienced an SMH within 30 days of anti-VEGF injection. Chi-square analysis found SMH more likely to occur within 30 days of anti-VEGF injection than after 30 days. CONCLUSIONS: Large SMH in neovascular AMD in a treat-and-extend regimen does not seem to be associated with prolonged dosing intervals or recent interval extension, and a large proportion of such hemorrhages are likely to be a result of mechanisms other than loss of effective VEGF inhibition.

Ultrasound-Guided Nerve Hydrodissection for Pain Management: Rationale, Methods, Current Literature, and Theoretical Mechanisms.

Nerve hydrodissection (HD), a technique used when treating nerve entrapments, involves the injection of an anesthetic, saline, or 5% dextrose in water to separate the nerve from the surrounding tissue, fascia, or adjacent structures. Animal models suggest the potential for minimal compression to initiate and perpetuate neuropathic pain. Mechanical benefits of HD may relate to release of nervi nervorum or vasa nervorum compression. Pathologic nerves can be identified by examination or ultrasound visualization. The in-plane technique is the predominant and safest method for nerve HD. Five percent dextrose may be favored as the preferred injectate based on preliminary comparative-injectate literature, but additional research is critical. Literature-based hypotheses for a direct ameliorative effect of dextrose HD on neuropathic pain are presented.

Shear Wave Elastography to Guide Perineural Hydrodissection: Two Case Reports.

Radial nerve palsy is not uncommon after humeral shaft fractures. Ultrasound-guided hydrodissection is an emerging treatment for nerve entrapment. Two cases of radial nerve injury after humeral shaft fractures with plate fixation are presented. Shear wave elastography was used to identify hardened scars surrounding the nerve, causing entrapment. These areas were marked on the skin as targets for ultrasound-guided hydrodissection. Each patient experienced full recovery of their radial nerve function. Shear wave elastography may be used to precisely identify sites of neural entrapment by scar tissue and accurately guide perineural hydrodissection, particularly in complex postoperative cases.

Influence of longwall mining on the stability of gas wells in chain pillars.

Longwall mining has a significant influence on gas wells located within longwall chain pillars. Subsurface subsidence and abutment pressure induced by longwall mining can cause excessive stresses and deformations in gas well casings. If the gas well casings are compromised or ruptured, natural gas could migrate into the mine workings, potentially causing a fire or explosion. By the current safety regulations, the gas wells in the chain pillars have to be either plugged or protected by adequate coal pillars. The current regulations for gas well pillar design are based on the 1957 Pennsylvania gas well pillar study. The study provided guidelines for gas well pillars by considering their support area and overburden depth as well as the location of the gas wells within the pillars. As the guidelines were developed for room-and pillar mining under shallow cover, they are no longer applicable to modern longwall coal mining, particularly, under deep cover. Gas well casing of failures have occurred even though the chain pillars for the gas wells met the requirements by the 1957 study. This study, conducted by the National Institute for Occupational Safety and Health (NIOSH), presents seven cases of conventional gas wells penetrating through longwall chain pillars in the Pittsburgh Coal Seam. The study results indicate that overburden depth and pillar size are not the only determining factors for gas well stability. The other important factors include subsurface ground movement, overburden geology, weak floor, as well as the type of the construction of gas wells. Numerical modeling was used to model abutment pressure, subsurface deformations, and the response of gas well casings. The study demonstrated that numerical models are able to predict with reasonable accuracy the subsurface deformations in the overburden above, within, and below the chain pillars, and the potential location and modes of gas well failures, thereby providing a more quantifiable approach to assess the stability of the gas wells in longwall chain pillars.

Laser vitreolysis for symptomatic floaters is not yet ready for widespread adoption.

Vitreous floaters are common, related to age, myopia, genetic predisposition, and infiltration of the vitreous body. A subset of patients report symptoms impacting their quality of vision. Treatment with laser vitreolysis, the use of an Nd:YAG laser to vaporize the collagenous vitreous opacities appears to be used more frequently; however, data regarding long-term safety and effectiveness are lacking. We present currently available data regarding efficacy and safety, as well as additional considerations. Laser vitreolysis of symptomatic floaters should not be routinely performed without additional studies documenting its safety and long-term efficacy. Ideally, the procedure would be effective in most patients and be approved by the Food and Drug Administration based on the results of a Food and Drug Administration registration trial before widespread adoption.

OCULAR HYPERTENSION AFTER INTRAVITREAL INJECTION OF 2-MG TRIAMCINOLONE.

PURPOSE: To report the incidence and course of ocular hypertension after intravitreal injection of 2-mg triamcinolone acetonide (IVT). METHODS: In a retrospective, consecutive series, all patients receiving 2-mg IVT at a single institution between March 1, 2012, and March 1, 2017, with a minimum of 3-month follow-up were reviewed. Ocular hypertension was defined as an intraocular pressure (IOP) measurement over 24 mmHg at any follow-up visit after IVT. Patients receiving topical, periocular, or intravitreal corticosteroid other than 2-mg IVT were excluded. RESULTS: A total of 106 eyes in 100 patients receiving at least one injection of 2-mg IVT were included. Eyes received an average of 2.9 injections (range 1-17), and average patient follow-up was 15.1 months (range 3.0-52.5 months). A total of 14 eyes (13.2%) in 14 patients developed ocular hypertension after a median of 1.5 injections (range 1-9) with an average peak IOP of 29 mmHg (range 25-38 mmHg). Overall, a total of 11 eyes (10.4%) had an IOP elevation ≥10 mmHg above baseline at any point after first IVT. In all cases of ocular hypertension, IOP was successfully managed with observation or topical IOP-lowering medication alone; no patients required surgical intervention. CONCLUSION: Ocular hypertension developed in 13.2% of eyes receiving intravitreal injection of 2-mg triamcinolone acetonide. Incidence of ocular hypertension after 2-mg IVT compares favorably with other intravitreally administered corticosteroids.

Sonoanatomy of the spine: a comprehensive scanning protocol from cervical to sacral region.

Ultrasound has been increasingly used in the musculoskeletal system, including the spine. In this protocol, the probe positionings, anatomical relationships, and ultrasound images of commonly scanned spinal structures are described. With an international consensus of several expert physiatrists i.e. USPRM; Ultrasound Study Group of ISPRM (International Society of Physical and Rehabilitation Medicine), this guide can provide a standardized approach for physicians who are interested in ultrasound diagnosis and guided pain interventions of the spine.

Refractive Outcomes after Pars Plana Vitrectomy and Scleral Fixated Intraocular Lens with Gore-Tex Suture.

PURPOSE: To evaluate refractive outcomes after combined pars plana vitrectomy (PPV) and scleral fixation of an intraocular lens (IOL) using Gore-Tex suture. DESIGN: Retrospective cohort study. PARTICIPANTS: Fifty-five eyes from 53 patients who underwent PPV with a Gore-Tex sutured IOL from June 2013 through December 2017. METHODS: Patients who underwent combined PPV and scleral fixation of an IOL with Gore-Tex suture were identified. All eyes underwent scleral fixation of either an Akreos A060 or enVista MX60 IOL and were fixated either 2 mm or 3 mm posterior to the limbus. Postoperative manifest refractions were performed at least 3 months after surgery and were compared with preoperative predicted target refraction based on in-the-bag IOL calculations. Subgroup analyses based on sclerotomy placement and IOL models were performed. MAIN OUTCOME MEASURES: Postoperative manifest refraction and difference with sclerotomy placement and IOL model. RESULTS: The mean postoperative spherical equivalent (SEQ) was -0.99±1.00 diopters (D). The mean difference in SEQ (ΔSEQ) from preoperative predicted target was -0.64±1.00 D. The IOL was fixated 2 mm posterior to the limbus in 14 eyes and 3 mm in 41 eyes. Within these 2 subgroups, the mean postoperative SEQ was -1.53±1.35 D for fixation 2 mm posterior to the limbus and -0.82±0.83 D for fixation 3 mm posterior to the limbus (P = 0.09). The mean ΔSEQ was -0.43±0.71 D for fixation 3 mm posterior to the limbus and -1.35±1.32 D for fixation 2 mm posterior to the limbus (P = 0.03). The mean amount of surgically induced astigmatism in the overall cohort was 0.77±0.65 D. The mean ΔSEQ and induced astigmatism were similar between IOL models. CONCLUSIONS: After combined PPV and Gore-Tex-sutured IOL implantation, mean postoperative refractive outcomes were more myopic when the IOL was fixated 2 mm from the limbus compared with 3 mm from the limbus. No significant difference was found between IOL models. Based on these results, future implant power calculations may be adjusted to approximate preoperative target refraction more accurately.

Rhegmatogenous Retinal Detachment after Intravitreal Injection of Anti-Vascular Endothelial Growth Factor.

PURPOSE: To report the rate, risk factors, and outcomes of rhegmatogenous retinal detachment (RRD) after intravitreal injection of anti-vascular endothelial growth factor medications. DESIGN: Single-center, retrospective, consecutive review. PARTICIPANTS: All patients receiving ranibizumab, bevacizumab, or aflibercept for neovascular age-related macular degeneration or retinal vein occlusion between October 1, 2014, and October 1, 2017. METHODS: The total number of eyes and injections were determined from billing codes. Rhegmatogenous retinal detachment patients were determined from billing records and confirmed with chart review. MAIN OUTCOME MEASURES: Rate of retinal detachment and visual acuity outcomes. RESULTS: A total of 180 671 intravitreal injections in 12 718 unique patients were included. An RRD occurred in 24 patients within 3 months after injection, giving a rate of 1 RRD per 7532 intravitreal injections (0.013%) and 1 RRD per 530 patients (0.19%). No association was found between RRD risk after injection and diagnosis (P = 0.54), physician experience (P = 0.23), injection site (P = 0.41), caliper use (P = 0.75), or 31- versus 30-gauge needle use (P = 0.18). A retinal tear was found located in the quadrant of the injection site (within 1.5 clock hours of the injection) in 15 of 24 patients (62.5%; P < 0.0001). At the time of RRD diagnosis, the macula was attached in 9 patients (37.5%). Interventions for RRD repair included pars plana vitrectomy (PPV; 15 patients), combined scleral buckle and PPV (4 patients), pneumatic retinopexy (3 patients), and laser or cryotherapy alone (2 patients). Single-surgery success rate was 54.2%, with 54.5% of recurrent detachments caused by proliferative vitreoretinopathy. Average loss from visual acuity recorded at the visit before diagnosis of RRD was 1.0 line for macula-on detachments versus 6.8 lines for macula-off detachments (P = 0.027) at final follow-up (average, 16.3 months). CONCLUSIONS: Retinal detachment after intravitreal injection is uncommon, with a rate of approximately 1 in 7500 injections. Macular status at the time of RRD diagnosis significantly affects visual outcomes.