Ultrasound-guided Genicular Nerve Blockade With Pharmacological Agents for Chronic Knee Osteoarthritis: A Systematic Review.

BACKGROUND: Ultrasound-guided (ULSD-g) genicular nerve blocks (GNB) using pharmacological agents for pain control in chronic knee osteoarthritis (OA) are gaining in popularity. There lacks a systematic review to evaluate the ULSD techniques and pharmacological agents used during the intervention, and to assess the knee's function postintervention. OBJECTIVES: Our study aimed to determine the clinical characteristics of patients with chronic knee OA selected for ULSD-g GNB, describe the various ULSD-g techniques and pharmacological agents used to target the genicular nerves, and evaluate the primary outcomes of pain and function. STUDY DESIGN: Systematic review. METHODS: We looked at patients with chronic knee OA with symptoms or disease features of at least 3 months and the use of ULSD guidance for GNB using either local anesthetic agents and/or corticosteroids or alcohol. Two major electronic databases (Medline/PubMed and EMBASE) were searched from their inception through August 2021, without language restriction.After removing duplicates, 2 reviewers independently reviewed the abstracts of 340 records. Nine of the 10 full texts that were reviewed were selected for inclusion. A third reviewer was involved in resolving disagreements.Two reviewers extracted relevant information pertaining to study types, patient characteristics, intervention details, outcome measures, and adverse effects. This was followed by independent verification for accuracy. RESULTS: Data synthesis: Nine studies were included with a total of 280 patients who had symptoms or disease features of at least 3 months. The National Institute of Health's Study Quality Assessment Tools were used for quality appraisal, of which 8 studies were at least of fair quality. All studies involved targeted at least the superior medial, superior lateral, and inferior medial genicular nerves. ULSD techniques relied on bony, soft tissue, or periarterial landmarks; either local anesthetic agents and/or corticosteroids or alcohol were used in the injections. Follow-up intervals for pain and functional assessments were heterogeneous, ranging from one week to 6 months postprocedure. Sustained improvements in both pain and knee function were observed for up to 6 months regardless of the choice of pharmacological agents. Minimal adverse effects were reported. LIMITATIONS: Meta-analysis was not performed due to heterogeneity of study designs, ULSD techniques, pharmacological agents used, and dosages administered. Only one study targeted additional genicular nerves; conclusions regarding the therapeutic blockade of these nerves could not be made. CONCLUSIONS: There is fair evidence to at least target the superior medial genicular nerve, inferior medial genicular nerve, and Inferior medial genicular nerve using local anesthetics, corticosteroids, or alcohol to reduce pain and to improve knee function in patients with chronic knee OA under ULSD guidance. The procedure is safe but more research is needed to determine the optimal interventional approach.

Ischemic lumbosacral plexopathy after embolization of type 2 endoleak: Progress and functional outcome.

An endoleak is a complication that can occur after an endovascular aneurysm repair. We report a rare case of ischemic lumbosacral plexopathy post embolization of type 2 endoleak, including its presentation, neurological progress, rehabilitation strategy and functional outcome.

Dextrose prolotherapy in knee osteoarthritis: A systematic review and meta-analysis.

OBJECTIVE: To summarize the evidence for dextrose prolotherapy in knee osteoarthritis. DATA SOURCES: The authors searched PubMed and Embase from inception to September 2020. All publications in the English language were included without demographic limits. STUDY SELECTION: Randomized clinical trials comparing the effects of any active interventions or placebo versus dextrose prolotherapy in patients with knee osteoarthritis were included. DATA EXTRACTION: Potential articles were screened for eligibility, and data was extracted independently. The risk of bias was assessed using the Cochrane Risk of Bias tool. Meta-analysis was performed on clinical trials with similar parameters. The Strength of Recommendation Taxonomy (SORT) was used for evaluating the strength of recommendations. DATA SYNTHESIS: In total, eleven articles (n = 837 patients) met the search criteria and were included. The risk-of-bias analysis revealed two studies to be of low risk. The overall effectiveness was calculated using a meta-analysis method. Prolotherapy was no different from platelet-rich plasma on the pain subscale at the 6-month time point. Prolotherapy was inferior to platelet-rich plasma at 6 months (MD 0.45, 95% CI 0.06-0.85, p = 0.03) on the stiffness subscale. Prolotherapy was found to be safe with no major adverse effects. CONCLUSION: Prolotherapy in knee osteoarthritis confers potential benefits for pain but the studies are at high risk of bias. Based on two well-designed studies, dextrose prolotherapy may be considered in knee osteoarthritis (strength of recommendation B). This treatment is safe and may be considered in patients with limited alternative options (strength of recommendation C).

Asymptomatic common extensor tendon pathology in patients with carpal tunnel syndrome.

INTRODUCTION/AIMS: Carpal tunnel syndrome (CTS) and lateral epicondylitis are both highly prevalent conditions. Our objective was to determine the prevalence of B-mode ultrasound abnormalities of the common extensor tendon (CET) in patients with CTS and establish the relationship between CET stiffness, as measured by shear wave elastography (SWE) and CTS severity. METHODS: Patients without symptoms or signs of lateral epicondylitis were recruited from referrals to a neurophysiology laboratory for possible CTS. These patients were examined for clinical features of CTS before undergoing electrodiagnostic testing followed by an ultrasound examination, consisting of B-mode, power Doppler, and SWE. RESULTS: Thirty-nine limbs with clinically diagnosed CTS and 20 control limbs were included. Of the CTS limbs, 61.5% had sonographically abnormal CET compared with 35% of the controls. The mean CET sonographic abnormality score was higher in CTS patients compared with controls (P = .006). CTS patients with sonographically abnormal CET had more severe CTS by electrophysiological criteria. The mean CET stiffness in CTS patients was lower than in controls (P = .033). DISCUSSION: Sonographic abnormalities of the CET are common in CTS patients with no clinical evidence of lateral epicondylitis and may relate to common pathogenetic mechanisms. These findings suggest that isolated ultrasound abnormalities in the CET are not diagnostically useful in patients presenting with upper limb pain unless there are clinical features of lateral epicondylitis.

Botulinum Toxin Injection and Electromyography in Patients Receiving Anticoagulants: A Systematic Review.

OBJECTIVE: To identify the different practice patterns of botulinum toxin injection (BTX) and electromyography (EMG) in patients receiving anticoagulation and to evaluate the incidence, reporting, and management of bleeding complications and compartment syndrome from BTX and EMG. LITERATURE SURVEY: Systematic review of relevant clinical studies in PubMed/Medline and Embase databases using key terms from inception to 31 May 2020. All publications in the English language were included without demographic limits. METHODOLOGY: A comprehensive search was performed to identify all studies addressing BTX and EMG in patients receiving anticoagulants. Two reviewers independently screened the titles, abstracts, and full texts and extracted data based on a set of predefined inclusion and exclusion criteria. All studies that met the inclusion criteria were assigned their respective levels of evidence using the Joanne Briggs Institute (JBI) Level of Evidence for Effectiveness. SYNTHESIS: Eighteen studies were included in this review of which there were nine studies each on BTX and EMG. The results indicated heterogeneity in the practice patterns of BTX and EMG in patients taking anticoagulants. These included the decision for continuation of anticoagulant, international normalized ratio (INR) results acceptable to practitioners, the modality for procedure guidance, and surveillance of bleeding complications. In addition, there were variations in the description of targeted muscles and description of needle sizes. The overall incidence of bleeding complications and compartment syndrome rates were low. CONCLUSIONS: Despite the varied practice in anticoagulated patients undergoing BTX or EMG, practitioners should allow periprocedural continuation of anticoagulants, targeting an INR of 2 to 3 while using the smallest needle (25 gauge or smaller) of appropriate length. Some of the evidence on procedural guidance and complication surveillance were weak and more research in these areas is required.

Shearwave Elastography in the Differentiation of Carpal Tunnel Syndrome Severity.

BACKGROUND: There is emerging evidence that ultrasound elastography may provide additional diagnostic information in peripheral neuropathies. OBJECTIVE: To investigate the use of ultrasound elastography to evaluate median nerve stiffness in patients with carpal tunnel syndrome (CTS), as well as the relationship between the elastographic stiffness and electrophysiological severity. DESIGN: Case control study. SETTING: Tertiary hospital outpatient neurophysiology clinic. PARTICIPANTS: Twenty eight patients (47 wrists) with CTS and 25 control patients (25 wrists). INTERVENTIONS: None. MAIN OUTCOME MEAURES: Ultrasound parameters (median nerve cross-sectional area [CSA] at carpal tunnel, ratio of median nerve CSA at carpal tunnel and forearm), shearwave elastography parameter (median nerve stiffness), and electrophysiological severity of carpal tunnel syndrome. RESULTS: In patients with CTS, median nerve stiffness by ultrasound elastography was increased between the different severity groups (control 83.5 ± 24.8, EDx negative CTS 84.2 ± 46.4, mild 117.7 ± 79.3, moderate 144.0 ± 71.1, severe 196.6 ± 48.4). The control versus moderate and severe subgroup was statistically significant. CONCLUSIONS: In total, this study has demonstrated that ultrasound elastography was able to discriminate the severity of CTS whereas conventional ultrasound parameters did not.

Ultrasound elastography for the evaluation of peripheral nerves: A systematic review.

Peripheral nerve disorders are commonly encountered in clinical practice. Electrodiagnostic studies remain the cornerstone of the evaluation of nerve disorders. More recently, ultrasound has played an increasing complementary role in the neuromuscular clinic. Ultrasound elastography is a technique that measures the elastic properties of tissues. Given the histological changes that occur in diseased peripheral nerves, nerve ultrasound elastography has been explored as a noninvasive way to evaluate changes in nerve tissue composition. Studies to date suggest that nerve stiffness tends to increase in the setting of peripheral neuropathy, regardless of etiology, consistent with loss of more compliant myelin, and replacement with connective tissue. The aim of this systematic review is to summarize the current literature on the use of ultrasound elastography in the evaluation of peripheral neuropathy. Limitations of ultrasound elastography and gaps in current literature are discussed, and prospects for future clinical and research applications are raised.

Case report of C5 palsy after C3-C6 posterior decompression and instrumented fusion in a patient undergoing inpatient rehabilitation.

We report on a patient who had neurological deterioration attributed to C5 palsy post C3-C6 posterior decompression and instrumented fusion. A 60-year old man was admitted after a fall from an electric scooter. MRI of the cervical spine confirmed severe cervical spondylosis causing cord compression at C4/5 with associated cord oedema. He underwent posterior cervical decompressive surgery, and he remained neurologically stable post operatively. However, he subsequently developed acute left upper limb weakness limited to the C5 myotome 1 week after surgery whilst undergoing inpatient rehabilitation. A repeat MRI of the cervical spine did not reveal any new changes that may explain his symptoms. He was started on intravenous dexamethasone. C5 palsy after cervical decompressive surgery is not uncommon. There is no specific evidence-based treatment and it carries a generally good prognosis. The aim of this case report is to highlight this complication and raise awareness amongst physicians.