Percutaneous Ultrasound-Guided Tenotomy of the Iliotibial Band for Trochanteric Pain Syndrome: A Longitudinal Observational Study With One-Year Durability Results.

BACKGROUND: Upper lateral hip pain is a common complaint in adults and is referred to as greater trochanteric pain syndrome (GTPS) and is more prevalent among older women. This is a debilitating condition that could result in lower physical activity and quality of life, and higher unemployment rate. GTPS is a clinical diagnosis, and many cases improve with conservative medical management (CMM). However, there is still a gap between patients not responding to CMM and those who are not good surgical candidates. Thus, percutaneous ultrasound tenotomy (PUT) may be a valuable treatment option to limit this gap. OBJECTIVES: Demonstration of the one-year pain and functional outcomes, including sit to stand. SETTING: Academic tertiary care medical center. METHODS: Forty-eight consecutive patients with refractory trochanteric pain due to iliotibial band (ITB) tendinopathy. Fifty-six hips were treated; 8 patients underwent bilateral procedures. Electronic medical record review of consecutive patients who underwent ITB TENEX® was performed at Montefiore Medical Center from December 2019 to December 2021. Institutional guidelines recommended TENEX® for greater trochanteric pain refractory to conservative treatment and ultrasound (US) confirmed ITB tendinopathy (hypoechogenicity or thickened tendon > 6 mm). Pain level, as well as sit-to-stand, side-lying, and walking tolerance levels were evaluated at baseline preprocedure visit and one-year visit. Follow-up was performed by independent practitioners and corroborated by chart review. RESULTS: Numeric Rating Scale (NRS-11) improved by 4 points across all patients. Seventy percent of patients endorsed pain relief at one-year visit. Median preprocedure NRS-11 was 9. The reported median NRS-11at one year was 5 (Wilcoxon signed rank NRS-11 demonstrated a Z score of -6.042 with P < 0.001). One-year analysis among all patients revealed 57%, 78%, and 66% improvement in side-lying, sit-to-stand, and walking tolerance levels, respectively. LIMITATIONS: We believe that our results must be confirmed with a randomized control trial with a control arm and more patients included. CONCLUSIONS: PUT of the ITB using the TENEX® tissue remodeling device could be a safe and effective treatment for ITB tendinopathy-associated GTPS.

Cross-Sectional Study Evaluating Clinical & Psychological Impact of Limited Access to Healthcare in Chronic Pain Patients During the COVID-19 Pandemic.

BACKGROUND: COVID-19 quarantine measures have created new challenges in the delivery of medical care, especially in the realm of medical and interventional chronic pain management. This study evaluated the effect of COVID-19 social distancing and quarantine measures on symptoms of pain and anxiety, as well as substance abuse and health care engagement in patients with chronic pain and the role of the clinic's virtual assessment initiatives in managing these patients. METHODS: A 24-question cross-sectional survey was conducted with patients with chronic pain seen at the Montefiore Medical Center Comprehensive Pain Clinic from June 2020 through July 2020. The survey was administered to 552 high-utilizer patients via telephone, evaluating domains such as pain, anxiety, substance use, and health care engagement. The questions were quantitively assessed on a Likert scale or a numerical rating scale. We used descriptive statistics to report our results. RESULTS: Of the 1,023 patients identified as high utilizers of the pain clinic, 552 patients participated in the survey. The median (25th-75th percentile) pain score reported was 7 (5-9) for all responders. Approximately 50% of the patients reported that they were anxious about their pain and somewhat or very concerned that their pain would be uncontrolled during the pandemic. Further, the severity of the pain reported was associated with sleep, appetite, and mood changes. In our cohort, 95% of all patients denied using alcohol, 92% denied using marijuana, and 98% denied using other recreational drugs to manage their pain during the pandemic. In addition, just more than three-fourths (79%) of all patients reported needing to speak with their health care provider during the pandemic. CONCLUSIONS: The survey conducted among high-utilizers demonstrated that patients who remained engaged with their health care team reported minimal concerns regarding chronic pain and associated symptoms during the COVID-19 quarantine period. In addition, the early implementation of virtual consults in the pain clinic may have contributed to mitigating patient concerns. Finally, the study also identified the importance of outreach and patient education on the availability and utilization of telemedicine services. Consequently, it is reasonable to implement virtual assessments and visits alongside other education outreach methods to engage patients with chronic pain who frequently utilize chronic pain health care resources.

MRI and Anatomical Determinants Affecting Neuroforaminal Stenosis Evaluation: A Descriptive Observational Study.

Purpose: Neuroforaminal stenosis (NFS), a narrowing of the intervertebral foramen, is a cause of disability in the aging population. Formal magnetic resonance imaging (MRI) classification of NSF has been developed recently and contradictory findings have been reported. This study aims to assess whether in-plane, anatomically conformed two-dimensional (2D) views of the neuroforamen characterize NFS more accurately than traditional axial, coronal, and sagittal views in healthy individuals with and without simulated scoliosis. Patients and methods: This observational study was approved by the designated institutional review board at our academic tertiary care center. Four volunteers underwent lumbar spine MRI twice, once in the supine position and once with intentionally introduced hip tilt. The latter resulted in lumbar curvature mimicking positioning errors approximating degenerative lumbar scoliosis. Anatomically oriented cuts such as axial with endplate correction and coronally obliqued parasagittals, also called coronal obliques, were performed. Standard sagittal and axial views were also performed in both the supine and rotated groups. Results: Coronal oblique and anatomically oriented axial views demonstrated the highest correlation with true neuroforaminal caliber. Deviation from anatomical congruence resulted in false measurements of neuroforaminal size. The hip-tilt studies produced MR that were less favorable to characterization of the caliber of neuroforamina. Coronal sections demonstrated reliability only when performed at the mid-pedicular lines. Standard axial views were reliable only when taken at the upper one-third of the neuroforamen. Coronal oblique views demonstrated superiority when evaluating consecutive neuroforamen on one image compared to non-obliqued parasagittal slices. Conclusion: To minimize error in neuroforaminal analysis, imaging specialists should perform anatomically oriented cuts to conform to individual patient anatomy. When this cannot be performed due to a patient's spine rotation or position, the MRI reader should view oblique, axial, and coronal images simultaneously and dynamically for proper foraminal characterization.

Sonographically Guided Percutaneous Sectioning of the Coracohumeral Ligament for the Treatment of Refractory Adhesive Capsulitis: Proof of Concept.

INTRODUCTION: Treatment options are limited for nonsurgical chronic refractory cases of adhesive capsulitis. We describe a novel percutaneous tenotomy technique for coracohumeral ligament interruption with cadaveric validation. OBJECTIVE: The objective of this study was to describe and validate a novel technique for percutaneous interruption of the coracohumeral ligament. DESIGN: Cadaveric study. SETTING: Academic tertiary care center. METHODS: Eight cadavers underwent ultrasound (US)-guided percutaneous incision of the coracohumeral (CHL) ligament. Performance of the procedure requires that the practitioner make oscillatory motions with a needle that uses ultrasound energy to cut through tissue. Each pass removes a pinhead-sized amount of tissue. The number of passes and the cutting time are recorded during the procedure. As a standard for this procedure does not exist, the authors created their own based on the preclinical information presented here. Postprocedure dissection was performed to assess the extent of CHL interruption and injury to surrounding tissue. RESULTS: The average resection time was seven minutes, requiring 500 passes. The technique described in this paper completely interrupted the CHL in all subjects. Cadaveric analysis demonstrated interruption of the CHL with respect to control shoulders requiring an average of seven minutes of cutting time and ∼500 micro-perforations. CONCLUSION: US-guided percutaneous CHL ligament sectioning is possible with a commercially available ultrasonic probe.