Explore the vast range of titles available.

This scoping review systematically evaluates and synthesizes evidence on the presence of neoinnervation in chronic tendon pain. By analyzing the frequency and progression of neural biomarker upregulation, the present investigation seeks to illuminate existing knowledge gaps, contextualize shifts in research focus over time, and propose potential therapeutic approaches for the more precise and effective management of tendinopathy. To identify major neural biomarkers associated with nerve ingrowth, detailing historical development, current understanding, and implications in tendinopathy. A scoping review. An academic medical center. Searches were conducted up to June 2024 using PubMed, Embase, Web of Science, and Scopus, adhering to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) guidelines. The selected studies included clinical human case-control studies and in vivo experimental animal models that examined neoinnervation in tendinopathy. Data extraction included study design, animal induction models, biomarker detection methods, neural biomarker upregulation, and supporting evidence to evaluate the involvement of neoinnervation and the role of the paratenon in tendinopathy. Of the 26 studies reviewed, 19 (73%) identified neoinnervation in chronic tendinopathy, and 20 (76.9%) highlighted the role of the paratenon, suggesting its potential as a key target for therapeutic interventions. Notably, 14 studies (53.8%) examined both neoinnervation and the paratenon's role, indicating significant interplay. Analyses of neural biomarkers revealed possible upregulation of protein gene product 9.5 (PGP 9.5) in 15 studies (57.6%) and substance P in 13 studies (50%), emphasizing the crucial roles of those biomarkers in the neurobiological mechanisms of tendinopathy pain. Other biomarkers, including calcitonin gene-related peptide (CGRP), tyrosine hydroxylase, growth-associated protein-43 (GAP-43), NMDA receptor (NMDAR), glutamate, neurokinin 1 receptor (NK1R), neuropeptide Y, adrenoreceptor, nerve sprouting markers, specific chemokines, and various immune-related markers, were also identified as potentially upregulated. Our review of temporal trends indicates that recent research has expanded to encompass a broader range of biomarkers, thereby enhancing our understanding of the complexity and multisystem involvement in the pathology of tendinopathy. This review is limited by the predominance of case-control and experimental studies, which inherently offer lower levels of evidence due to methodological constraints like lack of randomization and potential biases. Additionally, the present review may not fully address how biomarker expression or neoinnervation changes over disease stages or treatment, the comprehension of which is critical for understanding progression and management. The present investigation highlights the critical role of neoinnervation and the paratenon in chronic tendinopathy, with a significant overlap suggesting interrelated roles in the condition. This finding emphasizes the need to incorporate neurobiological pathways into therapeutic strategies. The evolution of neural biomarker studies reveals a complex interplay in pain mechanisms, underscoring the potential for targeting specific nerve ingrowth pathways within the paratenon to enhance treatment efficacy. Future research should aim to elucidate the therapeutic potential of targeting specific paratenon nerve ingrowth pathways, which could improve the efficacy of treatments for chronic tendon pain substantially.

Spinal cord stimulation is utilized in the management of a variety of pain states. Commonly, implanted stimulator systems lose their efficacy, resulting in explantation of the devices. Strategies beyond repositioning the leads have evolved in recent years. Replacing generators to deliver a new electrical signaling is known as \"salvage\" or \"rescue\" therapy. To assess the impact of testing multiple pulse generator systems during a salvage trial on clinical outcomes and cost-effectiveness in patients with failed primary SCS devices. Retrospective chart review. An academic health care institution. We retrospectively reviewed the charts of patients who were treated from 2016 to 2019, had previously been implanted with spinal cord stimulation (SCS) systems, and had subsequently undergone a salvage trial in the operating room. In all cases, the original SCS generator was explanted while the existing epidural lead array was preserved and connected to percutaneous extension leads. Those leads were externalized and attached to an alternative stimulation system. Patients underwent a one-week externalized trial with individualized parameter optimization. They then returned to the operating room for either permanent implantation or system removal. Data on changes in visual analog scale (VAS) scores, percent coverage, potential morphine equivalent daily dose (PMEDD), and trial outcomes were collected. We reviewed 20 serially treated patients who had been previously implanted with SCS systems and subsequently undergone a salvage trial in the operating room. The present investigation found, in a subgroup analysis of patients, that gender may play a role in the complexity of waveform selection. Average age was slightly higher in the multiple trial group (55.4 years versus 49.6 years), and both groups had comparable BMI values (32.6 versus 32.16). Patients in the multiple-trial group tended to proceed to salvage therapy sooner (3.5 years versus 4.9 years, P < 0.001). In summary, proprietary electrical signaling platform cycling seems to be an effective strategy for SCS salvage. Pre-trialing may improve implantation outcomes, and larger studies are warranted to develop best practice strategies for these chronic pain patients. Limitations include a small sample size, variability in follow-up timing, inconsistent reporting of clinical data, and the absence of standardized functional and quality-of-life outcome measures. Emerging stimulation paradigms such as burst and high-frequency stimulation present promising alternatives for patients with ineffective SCS systems. In cases wherein the existing device cannot support these modalities, an IPG externalization trial may serve as a low-risk strategy to potentially rescue and optimize therapy.

Background: The COVID pandemic has impacted almost every aspect of human interaction, causing global changes in financial, health care, and social environments for the foreseeable future. More than 1.3 million of the 4 million cases of COVID-19 confirmed globally as of May 2020 have been identified in the United States, testing the capacity and resilience of our hospitals and health care workers. The impacts of the ongoing pandemic, caused by a novel strain of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), have far-reaching implications for the future of our health care system and how we deliver routine care to patients. The adoption of social distancing during this pandemic has demonstrated efficacy in controlling the spread of this virus and has been the only proven means of infection control thus far. Social distancing has prompted hospital closures and the reduction of all non-COVID clinical visits, causing widespread financial despair to many outpatient centers. However, the need to treat patients for non-COVID problems remains important despite this pandemic, as care must continue to be delivered to patients despite their ability or desire to report to outpatient centers for their general care. Our national health care system has realized this need and has incentivized providers to adopt distance-based care in the form of telemedicine and video medicine visits. Many institutions have since incorporated these into their practices without financial penalty because of Medicare’s 1135 waiver, which currently reimburses telemedicine at the same rate as evaluation and management codes (E/M Codes). Although the financial burden has been alleviated by this policy, the practitioner remains accountable for providing proper assessment with this new modality of health care delivery. This is a challenge for most physicians, so our team of national experts has created a reference guide for musculoskeletal and neurologic examination selection to retrofit into the telemedicine experience. Objectives: To describe and illustrate musculoskeletal and neurologic examination techniques that can be used effectively in telemedicine. Study Design: Consensus-based multispecialty guidelines. Setting: Tertiary care center. Methods: Literature review of the neck, shoulder, elbow, wrist, hand, lumbar, hip, and knee physical examinations were performed. A multidisciplinary team comprised of physical medicine and rehabilitation, orthopedics, rheumatology, neurology, and anesthesia experts evaluated each examination and provided consensus opinion to select the examinations most appropriate for telemedicine evaluation. The team also provided consensus opinion on how to modify some examinations to incorporate into a nonhealth care office setting. Results: Sixty-nine examinations were selected by the consensus team. Household objects were identified that modified standard and validated examinations, which could facilitate the examinations.The consensus review team did not believe that the modified tests altered the validity of the standardized tests.Limitations: Examinations selected are not validated for telemedicine. Qualitative and quantitative analyses were not performed. Conclusions: The physical examination is an essential component for sound clinical judgment and patient care planning. The physical examinations described in this manuscript provide a comprehensive framework for the musculoskeletal and neurologic examination, which has been vetted by a committee of national experts for incorporation into the telemedicine evaluation. Key words: COVID, pain, telemedicine, physical examination, spine, shoulder, elbow, hand, hip, knee

Whereas traditional image guidance for placement of transforaminal epidural steroid injections (TFESI) has been fluoroscopy, it has disadvantages including inability to identify soft tissue, radiation exposure, and contrast administration need. Several studies found that ultrasonography is reliable in localizing lumbar nerve root. Few have investigated the feasibility of performing ultrasound guided TFESI in the lumbar spine. This study seeks to aid in filling this gap. Patients meeting inclusion criteria (BMI < 25) and exclusion criteria (no spinal deformity or previous lumbar surgery) were enrolled. Ultrasound visualization of nerve root and proximate placement of needle tip guided needle placement. Vascular signals were monitored. The contrast injection was done under real-time ultrasound visualization. Final needle placement with transforaminal epidural spread was assessed for accuracy by contrast fluoroscopy. Complications were assessed. Thirty ultrasound guided lumbar TFESI were performed. Visualization at the L2, L3, and L4 levels was successful. At the L5 level, needle tip was placed in proximity to the nerve root, but the final needle tip position for transforaminal placement and injection was not visualized; fluoroscopic guidance was used instead. There was no evidence of intravascular injection. No complications were noted. Ultrasonography shows feasibility as an imaging modality in localizing lumbar intervertebral foramina at higher lumbar levels in patients with normal BMI and no spinal deformities. However, ultrasonography was consistently unable to assist transforaminal needle placement at the L5 level due to poor final needle tip visualization and the requirement of fluoroscopy to advance needle tip transforaminally. While no complications were seen, further controlled trials with larger sample size are needed to investigate safety.

Keywords: chronic pain; disability; physical function; quality of life.

Scott G Pritzlaff,1 Miles Day,2 Sayed E Wahezi,3 Michael E Schatman4,5 On behalf of Pain Medicine Luminaries1Department of Anesthesiology and Pain Medicine, University of California, Davis, Sacramento, CA, USA; 2Traweek-Racz Endowed Professor in Pain Research, Department of Anesthesiology, Texas Tech University HSC, Lubbock, TX, USA; 3Departments of Rehabilitation Medicine, Anesthesiology, and Orthopedic Surgery, Montefiore Medical Center, Bronx, NY, USA; 4Department of Anesthesiology, Perioperative Care and Pain Medicine, NYU Grossman School of Medicine, New York, NY, USA; 5Department of Population Health – Division of Medical Ethics, NYU Grossman School of Medicine, New York, NY, USACorrespondence: Michael E Schatman, Department of Anesthesiology, Perioperative Care & Pain Medicine, NYU Grossman School of Medicine, 550 First Avenue, New York, NY, 10016, USA, Tel +1 425-647-4880, Email [email protected]

BACKGROUND: Radiofrequency ablation (RFA) is a common treatment in which radiofrequency (RF) is used to heat neural tissue and reduce pain. The impact of adipose content in tissue on the lesion size may impact efficacy, and to date, there is little, if any, data comparing its influence on RFA. OBJECTIVES: We evaluated the influence of adipose tissue on RF lesion size. STUDY DESIGN: Controlled, ex vivo study. SETTING: Academic institution in a procedural setting. METHODS: RF lesions were created using 20-G 10-mm protruding electrode (PE) needles inserted into unbrined chicken breasts and thighs at 21°C. RF current was applied for 90 seconds at 80°C. Chicken breasts were used as the control group and chicken thighs were used as the high adipose variant. Four different groups were examined: 1- Standard 20 g RFA needle, 2- 20 g RFA PE needle, 3- Standard RFA needle with lidocaine 2% injectate, and 4- Standard RFA needle with iohexol 240 mg injectate. There were 12 lesions performed in each group; length, width, and depth were measured. RESULTS: The control group had significantly deeper lesions in all 4 cohorts. Lesions’ lengths were smaller in the fat-rich group. The control and PE cohorts showed a significant difference in width between the 2 fat-rich and nonfatty groups. LIMITATIONS: Radiofrequency ablation was performed at room temperature and not heated to physiological temperature. This was an ex vivo study, thus factors of human anatomy and physiology could not be evaluated. CONCLUSIONS: Adipose tissue content was inversely related to lesion size in all samples. This factor should be considered when assessing methods of enhancing lesion size in human models. KEY WORDS: Radiofrequency, ablation, lesion size, injection, adipose tissue, tissue modeling, interventional pain, education

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. KEY WORDS: Surgery, novel, TENEX, iliotibial band, GTPS, function