Faculty Bibliography

(1) Spinal Cord Microglial Phenotypic Changes Following Sciatic Nerve Crush in CD137LKO Mice / David Nicholas, Kinuyo Ohara, Ling Cao -- (2) Notalgia Paresthetica Successfully Treated with Cervical Epidural Injection and Occipital Nerve Block: A Case Report / Fabienne Saint-Preux, Justin Mendoza, Salvador Portugal

Case Description: To report the use of a leukocyte-rich platelet-rich plasma injection in a patient with a T11-L1 interspinous ligament (ISL) sprain who had previously failed conservative management and corticosteroid injections.
Setting(s): Outpatient sports medicine clinic.
Patient(s): An otherwise healthy 25-year-old female. Assessment/Results: The patient presented to the clinic with a chief complaint of chronic upper lumbar and mid-thoracic back pain. Physical exam revealed full range of motion with pain at endpoint of lumbar flexion and tenderness to palpation. After a full examination, the patient was provided an initial ultrasound guided T11-L1 ISL injection with triamcinolone and referred for a course of physical therapy. Her pain had not resolved thus a second injection was performed with betamethasone. Several weeks post-procedurally, her pain persisted. Ultrasound examination revealed hypervascularity and edema in the soft tissue consistent with the diagnosis of an ISL sprain. This was subsequently confirmed with MRI. Afterwards, an injection of 3 mL of leukocyte-rich platelet rich plasma (LR-PRP; Arthrex Angel) was performed.
Discussion(s): The diagnosis of ISL sprains can be an elusive, particularly in a patient who presents with a chief complaint of back pain without prior trauma. Management of an ISL sprain typically involves activity modification. While it is impossible to prove, the repeat injection with a more potent corticosteroid may have contributed to the patient's ISL sprain. Thus, the use LR-PRP was employed given the theoretical benefit of promoting ligamentous healing with the various growth factors isolated in the injectate. Upon follow up with patient 3 months later, the patient noted improvement in pain and will be receiving an additional LR-PRP injection and further physical therapy.
Conclusion(s): For ISL sprains, the use of LR-PRP may be helpful in promoting tendon repair. This case report demonstrates an index case and further study of this application for PRP is warranted

Case Description: 33-year-old female with history of lumbar disc herniation with radiculopathy presents with radiating left sided neck pain for 1 week without inciting event. Cervical spine exam revealed left cervical paraspinal muscle, facet joint, upper trapezius and levator scapulae tenderness, and equivocal Spurling's sign. Patient was diagnosed with cervical radiculopathy likely secondary to cervical disc herniation. Oral steroids and physical therapy were prescribed. Six days later, patient presented to the ED with left arm/face numbness. Exam revealed decreased sensation in the V1/3 distribution and left arm. CTA head/neck revealed left cervical vertebral artery dissection, patient was started on daily aspirin and outpatient neurology follow up was advised.
Setting(s): Outpatient spine clinic Patient: 33-year-old female with radiating left sided neck pain Assessment/Results: Patient with clinical presentation of progressive left cervical radiculopathy was found to have a vertebral artery dissection as the true etiology of neck pain.
Discussion(s): Neck pain is a common complaint in spine clinic and the majority of cases are not life threatening. Incidence of cervical artery dissection is low; however, it is a common cause of stroke in adults younger than 50. Similar to cervical radiculopathy, cervical artery dissection can present with gradual neck pain and tenderness to palpation on exam, however the majority of patients also have severe headache which was not seen in this case.
Conclusion(s): Cervical artery dissection is a serious, albeit rare, cause of neck pain with a high potential for fatal sequelae. In cases of progressive neck pain despite use of oral steroids, cervical vertebral artery dissection should be considered as a potential cause of neck pain particularly in the context of new onset facial and arm numbness

Case Description: The patient is an elderly female who presented with left groin and hip pain for 2 weeks without an inciting event. Initial hip x-rays showed no acute pathology. Her pain was sharp, 10/10, and exacerbated by activity. Examination was suggestive of intra-articular pathology.
Setting(s): Outpatient office Patient: 93-year-old female with left groin and hip pain. Assessment/Results: Ultrasound of the left hip revealed evidence of discontinuity at the femoral neck with intra-articular effusion and increased Doppler flow with power Doppler imaging (PDI) within the joint capsule. Ultrasound-guided aspiration of the effusion revealed frank blood. Subsequent MRI showed mildly impacted and displaced subcapital left femoral neck fracture with associated reactive marrow edema and joint effusion. Patient was sent to the emergency room and underwent left hip pinning by orthopedic surgery.
Discussion(s): Although ultrasound with PDI is not part of a routine protocol for detecting hip fractures, it led to accurate diagnosis for this patient. The increased intraarticular Doppler signal seen with PDI reflected the intra-osseous blood flow into the joint capsule. While most hip fractures are detected with plain films, approximately 2-9% have negative or equivocal plain radiography results. Delayed diagnosis of occult hip fracture can result in avascular necrosis, nonunion, loss of function, and even increased mortality. If fracture is suspected, further imaging, such as CT or MRI, is needed. Reports on ultrasound for diagnosis are limited but promising. In a study of 30 patients with hip pain after trauma and inconclusive radiographs, ultrasound had 100% sensitivity and 65% specificity for detecting occult hip fractures. No studies included PDI in this setting which can increase diagnostic efficacy. Ultrasound could be an inexpensive screening tool for patients with suspected occult hip fracture in the office setting.
Conclusion(s): Ultrasound including PDI in the outpatient setting has potential as a cost-effective, highly sensitive screening tool for occult hip fractures

Case Description: A 42-year-old female secretary presented with acute painful swelling of her wrist and hand numbness. She complained of stabbing pain in her hand for 2 weeks without an inciting event and a painful, palpable cyst on her left forearm for 1 week, associated with numbness/tingling on the dorsum of her left hand and forearm. Pain was worse after prolonged computer use and with twisting motions. On examination, there was a fluid-filled cyst proximal to left ulnar wrist crease. Left digits 3-4 were tender to palpation and digits 3-5 were cool to touch. Allen's test was positive for ulnar artery occlusion. Ultrasound revealed occlusion of the ulnar artery from the distal forearm to Guyon's canal. Magnetic resonance angiography revealed occlusion of the distal ulnar artery with aneurysmal expansion indicating hypothenar hammer syndrome. The patient was referred for surgery and underwent ulnar artery excision of aneurysm with vein graft.
Setting(s): Outpatient clinic Patient: 42-year-old female secretary Assessment/Results: Hypothenar hammer syndrome after computer use.
Discussion(s): Hypothenar hammer syndrome is a rare, limb threatening diagnosis caused by repetitive trauma to the hypothenar eminence resulting in injury to the ulnar artery at the level of Guyon's canal. This has been described in middle-aged men with occupations such as manual laborers or mechanics and athletes who experience repetitive trauma to the palm such as in mountain biking or baseball. To our knowledge, this syndrome has rarely been seen in a younger female as a result of prolonged computer use. It is important to identify this condition in order to get appropriate treatment in a timely matter. The use of Doppler ultrasound is beneficial to hasten referral to the appropriate specialist.
Conclusion(s): It is important to consider the diagnosis of hypothenar hammer syndrome when evaluating a patient for wrist pain and numbness in order to prevent serious complications including limb ischemia