scholarly journals Characteristics of Patients With Complex Limb Pain Evaluated Through an Interdisciplinary Approach Utilizing Magnetic Resonance Neurography

2021 ◽  
Vol 2 ◽  
Author(s):  
Emily M. Johnson ◽  
Daehyun Yoon ◽  
Sandip Biswal ◽  
Catherine Curtin ◽  
Paige Fox ◽  
...  
Keyword(s):  
Magnetic Resonance ◽  
Lower Extremity ◽  
Case Series ◽  
Interdisciplinary Team ◽  
Limb Pain ◽  
Magnetic Resonance Neurography ◽  
Treatment Pathways ◽  
Lower Extremity Pain ◽  
Patient Reported ◽  
Team Evaluation

Patients with persistent complex limb pain represent a substantial diagnostic challenge. Physical exam, and tests such as nerve conduction, are often normal even though the patient suffers from severe pain. In 2015, we initiated a team-based approach to evaluate such patients. The approach included physicians from several specialties (Anesthesiology/Pain Medicine, Radiology, Plastic Surgery, Neurosurgery) combined with the use of advanced imaging with Magnetic Resonance Neurography (MRN). This preliminary case series discusses MRN findings identified in patients with previously difficult-to-diagnose peripheral limb pain and describes how this combination of approaches influenced our diagnosis and treatment plans. We extracted demographics, patient characteristics, presenting features, diagnostic tests performed, treatments provided, referral diagnosis and the diagnosis after interdisciplinary team evaluation from patient charts. We evaluated MRN and electrodiagnostic studies (EDX) ability to identify injured nerves. We compared abnormal findings from these diagnostics to patient reported outcome after ultrasound-guided nerve block. A total of 58 patients, 17 males and 41 females, were identified. The majority of patients presented with lower extremity pain (75%) and had prior surgery (43%). The most commonly identified abnormality on MRN was nerve signal alteration on fluid sensitive sequences, followed by caliber change and impingement. Comparing the outcome of diagnostic nerve blocks with abnormal nerve findings on MRN or EDX, we found that MRN had a sensitivity of 67% and specificity of 100% while for EDX it was 45 and 0%, respectively. After interdisciplinary discussion and imaging review, a more specific diagnosis was produced in 78% of evaluated cases opening up additional treatment pathways such as nerve-targeted surgery, which was performed in 36% cases. This descriptive case series demonstrates that a majority of patients evaluated by our team for complex limb pain were women with lower extremity pain resulting from surgery. In addition, an interdisciplinary team evaluation and the use of the moderately sensitive but highly specific MRN imaging modality resulted in a change in diagnosis for a majority of patients with complex limb pain. Future studies investigating patient outcomes after diagnosis change are currently underway based on the findings of this preliminary study.

Fascicular torsions of the anterior and posterior interosseous nerve in 4 cases: neuroimaging methods to improve diagnosis

2020 ◽  
Vol 132 (6) ◽  
pp. 1925-1929 ◽  
Author(s):  
Jennifer Kollmer ◽  
Paul Preisser ◽  
Martin Bendszus ◽  
Henrich Kele
Keyword(s):  
Magnetic Resonance ◽  
Surgical Intervention ◽  
Case Series ◽  
Diagnostic Methods ◽  
Posterior Interosseous Nerve ◽  
Nerve Ultrasound ◽  
Magnetic Resonance Neurography ◽  
Surgical Exploration ◽  
Hyperintense Signal ◽  
Emergency Surgical Intervention

Diagnosis of spontaneous fascicular nerve torsions is difficult and often delayed until surgical exploration is performed. This case series raises awareness of peripheral nerve torsions and will facilitate an earlier diagnosis by using nerve ultrasound (NUS) and magnetic resonance neurography (MRN). Four patients with previously ambiguous upper-extremity mononeuropathies underwent NUS and 3T MRN. Neuroimaging detected proximal torsions of the anterior and posterior interosseous nerve fascicles within median or radial nerve trunks in all patients. In NUS, most cases presented with a thickening of affected nerve fascicles, followed by an abrupt caliber decrease, leading to the pathognomonic sausage-like configuration. MRN showed T2-weighted hyperintense signal alterations of fascicles at and distal to the torsion site, and directly visualized the distorted nerves. Three patients had favorable outcomes after being transferred to emergency surgical intervention, while 1 patient with existing chronic muscle atrophy was no longer eligible for surgery. NUS and MRN are complementary diagnostic methods, and both can detect nerve torsions on a fascicular level. Neuroimaging is indispensable for diagnosing fascicular nerve torsions, and should be applied in all unclear cases of mononeuropathy to determine the diagnosis and if necessary, to guide surgical therapies, as only timely interventions enable favorable outcomes.

A Case Series of Successful Repair of Articular Cartilage Fragments in the Knee

2019 ◽  
Vol 47 (11) ◽  
pp. 2589-2595 ◽  
Author(s):  
Jessica L. Churchill ◽  
Aaron J. Krych ◽  
Mark J. Lemos ◽  
Morganne Redd ◽  
Kevin F. Bonner
Keyword(s):  
Magnetic Resonance Imaging ◽  
Magnetic Resonance ◽  
Internal Fixation ◽  
Scale Score ◽  
Case Series ◽  
Resonance Imaging ◽  
Patient Reported ◽  
Activity Scale ◽  
Chondral Fracture

Background: It is unclear whether chondral fragments without bone have the potential to heal after fixation. Controversy exists and opinions differ regarding the optimal treatment of chondral defects after pure chondral fracture. Purpose: To determine clinical and radiographic outcomes after internal fixation of traumatic chondral fragments repaired to bone in the knee. Study Design: Case series; Level of evidence, 4. Methods: A retrospective clinical and radiographic evaluation of 10 male patients with a mean age of 14.6 years (range, 10-25 years) at the time of surgery was performed. Eight of 10 patients were skeletally immature. Patients were selected by operating surgeons per the presence of a large displaced pure chondral fragment on magnetic resonance imaging and confirmed on intraoperative inspection. All patients had a diagnosed traumatic displaced pure chondral fracture of the knee (without bone) and underwent internal fixation with minimum 1-year follow-up. Validated patient-reported and surgeon-measured outcomes were collected pre- and postoperatively. All patients were evaluated at a mean 56 months postoperatively. Results: At surgery, the mean defect size that was primarily repaired with the displaced chondral fragment was 1.9 × 2.0 cm. With minimum 1-year follow-up, there were no clinical failures. All 8 patients who had subsequent magnetic resonance imaging follow-up had radiographic evidence of complete healing of the chondral fragment back to bone. At a mean follow-up of 56 months (range, 13-171 months; median, 36 months), patients had a mean International Knee Documentation Committee score of 94.74 (range, 87.4-100), a mean Marx Activity Scale score of 14.4 (range, 8-16), and a mean Tegner Activity Scale score of 7 (range, 5-9). At final follow-up, all patients except 1 returned to sports. Conclusion: The treatment of large traumatic chondral fragments is controversial. In this select series of 10 young patients who underwent primary repair with internal fixation, there were no failures clinically. Patients demonstrated excellent short-term clinical and radiographic results after fixation of these relatively large chondral fragments in the knee.

Morphological correlates of oxaliplatin induced peripheral neuropathy assessed by magnetic resonance neurography.

2017 ◽  
Vol 35 (15_suppl) ◽  
pp. 10092-10092
Author(s):  
Leonidas Apostolidis ◽  
Daniel Schwarz ◽  
Annie Xia ◽  
Markus Weiler ◽  
Sabine Heiland ◽  
...  
Keyword(s):  
Peripheral Neuropathy ◽  
Magnetic Resonance ◽  
Sciatic Nerve ◽  
Qualitative Evaluation ◽  
Magnetic Resonance Neurography ◽  
Imaging Protocol ◽  
Morphological Alterations ◽  
Patient Reported ◽  
Neuroprotective Strategies

10092 Background: Oxaliplatin induced peripheral neuropathy (OXA-PNP) is a frequent side effect of oxaliplatin containing chemotherapy protocols. It is commonly assessed clinically via physical examination and patient reported symptoms. Research has been impeded by the lack of objective tests to quantify OXA-PNP. Neurophysiological examination is time-consuming and can only cover a selected part of the examined nerve. The aim of this study was to investigate in-vivo morphological correlates of OXA-PNP by magnetic resonance neurography (MRN). Methods: 20 patients with mild to moderate OXA-PNP and 20 matched controls were prospectively enrolled. All patients underwent a detailed neurophysiology examination prior to neuroimaging. A standardized MRN imaging protocol at 3.0 Tesla with large-coverage included the lumbosacral plexus, as well as both sciatic nerves and their branches using T2-weighted fat-saturated sequences at high resolution. Qualitative evaluation of sciatic, tibial, and peroneal nerves were performed by two readers regarding the presence, degree, and distribution of nerve lesions. Quantitative assessment included volumetry of the dorsal root ganglia (DRG) and sciatic nerve normalized T2 (nT2) signal and caliber. Results: Significant DRG hypertrophy in OXA-PNP patients (207.3±47.7mm3 vs. 153.0±47.1mm3 in controls, p = 0.001) was found as morphological correlate of the sensory neuronopathy. Peripheral nerves only exhibited slight morphological alterations qualitatively. Quantitatively, sciatic nerve caliber was unchanged (26.0±5.1mm2 vs. 27.4±7.4mm2, p = 0.19) while sciatic nerve nT2 signal was slightly and non-significantly elevated in patients (1.32±0.22 vs. 1.22±0.26, p = 0.19). Conclusions: OXA-PNP leads to morphological correlates that can be detected in-vivo by MRN. Significant hypertrophy of the DRG was observed, a phenomenon which has not been described in OXA-PNP previously. DRG volume should be investigated as a biomarker in other sensory peripheral neuropathies and ganglionopathies as well as in studies evaluating neuroprotective strategies for OXA-PNP.

Magnetic Resonance Neurography of Peripheral Nerve Lesions in the Lower Extremity

Neurosurgery ◽  
1996 ◽  
Vol 39 (4) ◽  
pp. 750-756 ◽  
Author(s):  
Charles Kuntz ◽  
Lindsey Blake ◽  
Gavin Britz ◽  
Aaron Filler ◽  
Cecil E. Hayes ◽  
...  
Keyword(s):  
Magnetic Resonance ◽  
Lower Extremity ◽  
Peripheral Nerve ◽  
Magnetic Resonance Neurography ◽  
Nerve Lesions ◽  
Peripheral Nerve Lesions

Patient-Reported Outcomes Following Fasciotomy for Chronic Exertional Compartment Syndrome

2018 ◽  
Vol 11 (5) ◽  
pp. 471-477 ◽  
Author(s):  
Jacqueline M. Maher ◽  
Emily M. Brook ◽  
Christopher Chiodo ◽  
Jeremy Smith ◽  
Eric M. Bluman ◽  
...  
Keyword(s):  
Lower Extremity ◽  
Compartment Syndrome ◽  
Patient Reported Outcomes ◽  
Case Series ◽  
Lower Extremity Function ◽  
Five Dimensions ◽  
Chronic Exertional Compartment Syndrome ◽  
Patient Reported ◽  
Exertional Compartment Syndrome

Background. Lower extremity chronic exertional compartment syndrome (CECS) can negatively affect exercise and activity and may require operative intervention to release the fascia. Few studies have evaluated or compared patient-reported outcomes for bilateral versus single-leg staged fasciotomy and number of compartments released. Methods. A total of 27 eligible patients who underwent a fasciotomy procedure for CECS at a single institution were identified. A retrospective review of the medical record was performed, and individuals were contacted by phone to collect patient-reported outcomes, including ability to return to desired exercise level, postoperative expectation assessment, European Quality of Life—Five Dimensions, and the Foot and Ankle Ability Measure sports subscale. Results. A total of 21 patients were available for follow-up (average follow-up 36.9 months). The average single numeric assessment evaluation of lower-extremity function in sport was 87.5% in those who underwent a simultaneous bilateral fasciotomy (n = 10), 94% in those who had a staged unilateral fasciotomy (n = 5), and 74% in those who underwent an isolated single-leg fasciotomy. In all, 91% (n = 10) of patients who had all 4 compartments released intra-operatively were able to return to their desired exercise level versus 66.7% (n = 6) of those who did not have all 4 compartments released. Conclusion. The patient-reported outcomes of a staged unilateral fasciotomy and simultaneous bilateral fasciotomy for CECS are similar. Those who did not have all 4 compartments released reported worse outcomes. Further research should be conducted on the short-term outcomes and cost-effectiveness of a bilateral versus staged fasciotomy procedure. Levels of Evidence: Level IV: Case series

scholarly journals Osteochondral Allograft Transplant of the Patella Using Femoral Condylar Allografts: Magnetic Resonance Imaging and Clinical Outcomes at Minimum 2-Year Follow-up

2020 ◽  
Vol 8 (10) ◽  
pp. 232596712096008
Author(s):  
Kenneth M. Lin ◽  
Dean Wang ◽  
Alissa J. Burge ◽  
Tyler Warner ◽  
Kristofer J. Jones ◽  
...  
Keyword(s):  
Magnetic Resonance Imaging ◽  
Magnetic Resonance ◽  
Clinical Outcomes ◽  
Case Series ◽  
Osteochondral Allograft ◽  
Resonance Imaging ◽  
Short Term ◽  
Patient Reported ◽  
Mri Scans

Background: Fresh osteochondral allograft transplant (OCA) has good outcomes in the knee. However, donor tissue for patellar OCA is limited. Outcomes after nonorthotopic OCA of the patella using more readily available femoral condylar allograft (FCA) tissue have not been previously reported. Purpose: To assess short-term magnetic resonance imaging (MRI) and minimum 2-year clinical outcomes of nonorthotopic patellar OCA using an FCA donor. Study Design: Case series; Level of evidence, 4. Methods: A prospective institutional cartilage registry was reviewed to identify patients treated with patellar OCA using an FCA donor between August 2009 and June 2016. OCA plugs were obtained from the FCA at its trochlear-condylar junction and implanted into the recipient patellar lesion. Early postoperative MRI scans were graded by a blinded musculoskeletal radiologist using the Osteochondral Allograft MRI Scoring System (OCAMRISS). International Knee Documentation Committee Subjective Knee Evaluation Form (IKDC), Knee Outcomes Survey–Activities of Daily Living (KOS-ADL), and pain visual analog scale (VAS) scores were collected preoperatively and at minimum 2 years postoperatively, and outcomes were compared using the paired t test. Results: A total of 25 patients were included for clinical outcome analysis and 20 patients for MRI analysis. MRI scans obtained at a mean of 11.4 months (range, 6-22 months) postoperatively showed a mean total OCAMRISS score of 9.0 (range, 7-11); mean bone, cartilage, and ancillary subscores were 2.6, 3.7, and 2.6, respectively. At the latest follow-up (mean, 46.5 months; range, 24-85 months), postoperative improvements were noted in IKDC (from 45.0 to 66.2; P = .0002), KOS-ADL (from 64.3 to 80.4; P = .0012), and VAS (from 5.1 to 3.4; P = .001) scores, with IKDC and KOS-ADL scores above the corresponding previously reported minimal clinically important difference. Conclusion: In this study, patellar OCA using nonorthotopic FCA led to significant short-term improvements in pain and patient-reported outcomes. The majority of nonorthotopic patellar grafts demonstrated full osseous incorporation and good restoration of the articular surface on MRI at short-term follow-up.

Clinical Characteristics of Patients Diagnosed with Strongyloidiasis in a United States Urban Outpatient Dermatology Department: A Case Series

2017 ◽  
Vol 1 (3) ◽  
pp. 156-160
Author(s):  
Jacqueline Watchmaker ◽  
Sean Legler ◽  
Dianne De Leon ◽  
Vanessa Pascoe ◽  
Robert Stavert
Keyword(s):  
United States ◽  
Case Series ◽  
The United States ◽  
Screening Tools ◽  
Dermatology Department ◽  
Cutaneous Manifestations ◽  
Serologic Testing ◽  
Patient Reported ◽  
History Of ◽  
Endemic Areas

Background: Although considered a tropical disease, strongyloidiasis may be encountered in non-endemic regions, primarily amongst immigrants and travelers from endemic areas.  Chronic strongyloides infection may be under-detected owing to its non-specific cutaneous presentation and the low sensitivity of commonly used screening tools. Methods: 18 consecutive patients with serologic evidence of strongyloides infestation who presented to a single urban, academic dermatology clinic between September 2013 and October 2016 were retrospectively included.  Patient age, sex, country of origin, strongyloides serology titer, absolute eosinophil count, presenting cutaneous manifestations, and patient reported subjective outcome of pruritus after treatment were obtained via chart review.  Results: Of the 18 patients, all had non-specific pruritic dermatoses, 36% had documented eosinophila and none were originally from the United States. A majority reported subjective improvement in their symptoms after treatment. Conclusion:  Strongyloides infection and serologic testing should be considered in patients living in non-endemic regions presenting with pruritic dermatoses and with a history of exposure to an endemic area.Key Points:Chronic strongyloidiasis can be encountered in non-endemic areas and clinical manifestations are variableEosinophilia was not a reliable indicator of chronic infection in this case series Dermatologists should consider serologic testing for strongyloidiasis in patients with a history of exposure and unexplained pruritus

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