Determine the effectiveness of spinal cord stimulation (SCS) for the treatment of axial low back pain (LBP) with or without leg pain.Systematic review.Persons aged ≥18 with axial LBP with or without accompanying leg pain.Traditional low-frequency, burst, or high-frequency SCS.Sham, active standard of care treatment, or none.The primary outcome was ≥50% pain improvement, and the secondary outcome was functional improvement measured six or more months after treatment intervention.Publications in PubMed, MEDLINE, and Cochrane databases were reviewed through September 19, 2019. Randomized or nonrandomized comparative studies and nonrandomized studies without internal controls were included. The Cochrane Risk of Bias Tool and GRADE system were used to assess individual study characteristics and overall quality.Query identified 262 publications; 17 were suitable for inclusion. For high-frequency SCS, the only level 1 study showed that 79% (95% confidence interval = 70-87%) of patients reported ≥50% pain improvement. For low-frequency SCS, the only level 1 study reported no categorical data for axial LBP-specific outcomes; axial LBP improved by a mean 14 mm on the visual analog scale at six months. Meta-analysis was not performed due to study heterogeneity.According to GRADE, there is low-quality evidence that high-frequency SCS compared with low-frequency SCS is effective in patients with axial LBP with concomitant leg pain. There is very low-quality evidence for low-frequency SCS for the treatment of axial LBP in patients with concomitant leg pain. There is insufficient evidence addressing the effectiveness of burst SCS to apply a GRADE rating.
Objectives: The ulnar collateral ligament (UCL) is one of the most common sites of injury in baseball pitchers, with 25% of Major League Baseball (MLB) pitchers having undergone surgical reconstruction (UCLR). It remains unknown whether the ligament can respond to the stress of pitching. The purpose this study is to determine the response of the UCL in professional pitchers to pitching through a prospective ultrasonographic study. Methods: This was a prospective study supported by the Major League Baseball Research Committee. All pitchers within a single professional baseball club were enrolled. Pitching exposure history data including number of years pitching and peak pitch velocity were collected. A full ultrasound (US) examination of the ligament was then performed by a single fellowship-trained ultrasonographer with extensive experience with UCL US. This US examination was performed at the beginning of the season and then repeated at end of the season. This US examination included measurement of UCL thickness and valgus laxity, as measured via ulnotrochlear joint opening at 30° of flexion to valgus stress of 10% of the mean pitching torque of 64 Nm. Two US images were saved for each measurement such that all measurements were made twice and analysis was performed on the average. Thirty ultrasounds were measured by a second experienced ultrasonographer to determine inter-rater reliability via intra-class correlation coefficients (ICC). Correlation analyses were performed between pre-season data and pitching exposure data. Both paired and unpaired analyses compared pre- and post-season data. Results: 94 pitchers were included prior to the season and 83 were included at the completion of the season. With player movement in and out of the active roster, follow-up rate was 70% (46/66) of those available. These pitchers were 24±3 years old (mean±standard deviation), had 12±6 years pitching experience, and had peak velocity of 95±2 miles per hour. 13 pitchers (9%) had undergone UCLR prior to enrollment and 9 (6%) underwent UCLR after enrollment. With examination of US data, ICCs were 0.742 for UCL thickness and 0.878 and 0.871 for UCL laxity without and with stress at 30° respectively. Peak pitch velocity positively correlated with UCL thickness (ρ= 0.268, p=0.009) and valgus laxity at 30° (ρ= 0.266, p=0.010). In both paired and unpaired analyses, UCL thickness increased during the season (p=0.006 and 0.033 respectively). In the paired analysis valgus laxity at 30° increased non-significantly (p=0.069) and in the unpaired analysis, valgus laxity at 30° increased significantly (p=0.013). Conclusion: The ulnar collateral ligament responds to stress in professional pitchers. The UCL thickens and becomes more lax in response to higher pitch velocity and more years of pitching. The UCL thickens and valgus laxity increases with the stress of a single season of pitching. Our study will gather data on the same pitchers at the beginning of the next season to understand the healing response of the ligament to rest.
Abstract The objective was to determine the effectiveness of fluoroscopically guided genicular nerve radiofrequency ablation for painful knee osteoarthritis. Primary outcome measure was improvement in pain after 6 mos. Secondary outcomes included the Oxford Knee Score and Western Ontario and McMaster Universities Osteoarthritis Index. Two reviewers independently assessed publications before October 10, 2020. The Cochrane Risk of Bias Tool and Grades of Recommendation, Assessment, Development, and Evaluation system were used. One hundred ninety-nine publications were screened, and nine were included. Six-month success rates for 50% or greater pain relief after radiofrequency ablation ranged from 49% to 74%. When compared with intra-articular steroid injection, the probability of success was 4.5 times higher for radiofrequency ablation (relative risk = 4.58 [95% confidence interval = 2.61–8.04]). When radiofrequency ablation was compared with hyaluronic acid injection, the probability of treatment success was 1.8 times higher (relative risk = 1.88, 95% confidence interval = 1.38–2.57). The group mean Oxford Knee Score and Western Ontario and McMaster Universities Osteoarthritis Index scores improved in participants receiving genicular radiofrequency ablation compared with intra-articular steroid injection and hyaluronic acid injection. According to Grades of Recommendation, Assessment, Development, and Evaluation, there is moderate-quality evidence that fluoroscopically guided genicular radiofrequency ablation is effective for reducing pain associated with knee osteoarthritis at minimum of 6 mos. Further research is likely to have an important impact on the current understanding of the long-term effectiveness of this treatment.
Corticosteroid injections into tendon sheaths are common in clinical practice for treatment of a variety of tendon disorders. Previous systematic reviews have been performed on injections for stenosing tenosynovitis (DeQuervain tenosynovitis and trigger finger), but little high-level evidence remains for other tendon sheath injections. This systematic review analyzes the available literature on improvements in pain and function after these injections.This systematic review of MEDLINE and Embase databases, as well as article bibliographies, examined studies of adult tendon sheath injections, excluding DeQuervain and trigger finger injections. Studies with and without comparison groups were examined. Risk of bias assessment was additionally performed.Abstracts from 1293 records were screened, and 187 full-text articles were reviewed. Seven articles met final inclusion criteria, of which five were prospective trials and none were compared with a placebo. The proximal biceps, peroneal, finger flexor, and posterior tibialis tendons were explicitly examined. All articles reported at least short-term improvements in pain, and some reported improvement in function.Low-quality studies exist that suggest tendon sheath injections may provide at least short-term improvement in pain. Controlled studies are required to fully demonstrate efficacy.
Abstract Botulinum toxin (BTX) injections into the musculature surrounding the brachial plexus have been examined as a potential treatment for neurogenic thoracic outlet syndrome (nTOS). This systematic review identified 15 publications, of which one was a randomized controlled trial. BTX injections performed with ultrasound or electromyographic guidance, and with the inclusion of the pectoralis minor muscle, in addition to the anterior and/or middle scalenes, tended to provide greater symptom improvement and may predict response to first rib resection. Importantly, most studies were of low quality; thus, the results should be interpreted with caution. Further high‐quality studies are needed to confirm these findings.
Youth mountain bike racing is a rapidly growing sport in the United States. An injury surveillance system (ISS) is now implemented through a collaboration between University of Utah researchers and the National Interscholastic Cycling Association (NICA), referred to as NICA-ISS, to better understand injury characteristics in this sport and pursue data-driven injury prevention strategies.
Objective
Describe types of and factors associated with injuries sustained by youth mountain bike racers during NICA-sanctioned mountain bike racing and training.
Design
NICA-ISS was developed using a web-based system. Data were collected from NICA leagues during the 2018–2020 seasons. Designated reporters on each team were asked to complete weekly incident and exposure report forms.
Setting
Nation-wide youth mountain biking leagues in the United States.
Participants
Student-athletes on NICA teams in grades 8–12 participating in the 2018–2020 seasons.
Assessment of Risk Factors
Variables analyzed included injury characteristics, athlete demographics, trail conditions, incline during crash, weather, crash circumstances (practice, race, passing, trail familiarity), and health factors (dehydration, sleep, illness).
Main Outcome Measurements
Proportions/rates of injuries overall, by type and location, and by group of athletes.
Results
Injuries were tracked in 66,588 student-athlete-years, resulting in 2,587 injuries in 1,677 student-athlete injury events reported. The most commonly reported injury was concussion (23.3%), followed by injury to the wrist/hand (22.7%), shoulder (16.7%), and knee (14.3%). Over a half (52.1%) of injury events occurred on downhills. Males and females reported similar injury rates (2.43% and 2.86%, respectively), but females sustained significantly more lower limb injuries (p = 0.003). A large portion (72.4%) of injured athletes were unable to complete the ride; 49.3% of crashes resulted in an emergency room visit.
Conclusions
Acute traumatic injuries are common in mountain bike racing, including concussions and injuries to the upper extremities. Males and females have similar injury rates but different injury types. To our knowledge, this is the largest mountain bike racing ISS in existence.
Identify if extended-release triamcinolone has a longer duration of action in a cohort of patients who have had limited duration of relief from prior corticosteroid injection.
Abstract Background Trigger finger is a common cause of hand pain. Though multiple techniques for percutaneous A1 pulley release have been described in the literature, there is a continued need for safe and effective techniques using inexpensive, familiar, and commonly found instruments. This study evaluated outcomes of percutaneous A1 pulley release performed using a novel technique with a modified 20‐gauge spinal needle and ultrasound guidance, with follow‐up outcomes at least 6 months after the procedure. Objective To evaluate the efficacy and safety of a novel percutaneous A1‐pulley release technique in individuals with trigger finger. Design Retrospective observational study. Setting Private practice outpatient orthopedics clinic. Participants Forty digits from 30 unique patients with trigger finger who underwent percutaneous A1 pulley release. Interventions Percutaneous ultrasound‐guided A1 pulley release performed with a modified 20‐gauge spinal needle. Main Outcome Measures The primary outcome measure was cessation of triggering. Secondary measures examined intraoperative and postoperative pain, postprocedural duration of activity limiting pain, and time to perform the procedure. Results Immediate cessation of triggering was achieved in all 40 digits following the procedure, with no recurrence reported at any time at an average follow‐up of 11 months (range 6–32). Patients reported returning to normal activity in 2.75 days. Only one minor complication was reported, tenosynovitis, which resolved with a corticosteroid injection. Conclusions Percutaneous, ultrasound‐guided A1 pulley release performed with a modified 20‐gauge spinal needle can be safely performed with good outcomes and a rapid return to normal activity.
