735 Myocardial ischaemia: not just about obstructive coronary arteries

Aims A vast proportion of subjects with anginal symptoms undergoing invasive coronary angiography (ICA) suffer from ischaemia with non-obstructive coronary arteries (INOCA). This condition has many contributing mechanisms, including epicardial vasospasm caused by vasomotor disorder, which is characterized by ST-segment changes during the self-limiting chest pain episodes. The diagnosis of this condition is challenging. Although different provocative test could performed during ICA (e.g. intracoronary administration of acetylcholine or ergonovine), their use is uncommon. Methods and results Clinical case A 39-years old man, smoker, hypertensive and dyslipidemic, presented to the emergency department after a Holter dynamic ECG detecting transient ST-segment elevation in the D1 lead. He had recurrent rest angina despite medical therapy and a prior ICA performed one year before the current presentation documented a mild stenosis of the posterior descending artery, a moderate stenosis of a duplicated left anterior descending artery, and a chronic total occlusion of the left obtuse marginal, which was not revascularized because of the absence of inducible ischaemia on single-photon emission computed tomography. The new ICA performed at presentation revealed a significant progression of coronary artery disease at the level of the posterior descending artery, which was treated through percutaneous coronary intervention, while the other vessels were unchanged. During the procedure, the patient experienced severe angina with ST-segment elevation and angiographically evident vasospasm of left coronary artery. The instantaneous wave-free ratio measurement performed on the medial branch of the duplicated left anterior descending artery was 0.86, which quickly resolved after administration of nitrate (0.93). Calcium channel blockers were added to medical therapy and the patient was discharged asymptomatic. Conclusions Vasospastic angina can cause ischaemia both in the presence and in the absence of visible atherosclerosis. This cause of INOCA often remains undetected but it is relatively frequent especially among younger patients who continue experiencing angina leading to repeated hospitalizations. The chance of this condition should be always taken into account, and the correct diagnosis should be obtained not incidentally like in the present case, but following standardized intracoronary test in a proper setting.

Preliminary Results of Endoscopic Radiofrequency Treatment of the Sacroiliac Joint Syndrome

Background and Study The sacroiliac joint (SIJ) may be the primary source of pain in 15 to 25% of patients with axial low back pain. Furthermore, 75% of patients who have had fusion surgery develop SIJ pain within 10 years. Treatment options include SIJ blocks, radiofrequency (RF) denervation, and fusion. The RF techniques range from ablation of the nerves supplying the joint, creating lesions to the joint itself, or a combination of both techniques. However, different clinical studies could only identify a limited or, in some cases, no effect in decreasing of pain intensity and duration of the effect. Methods In this retrospective study, we selected 23 patients with SIJ pain, with a duration of more than 12 months and a 50% pain reduction on the Numeric Rating Scale (NRS) after diagnostic block. All patients received endoscopic ablation of the medial branch L5/S1 and the lateral branches, exiting the sacral foramina on S1/S2 and S2/S3 on both sides while using only one incision on each side. Telephone interviews were conducted with all patients. The outcome was determined with Odom's criteria, percent reduction NRS, subjective assessment of the patient, and duration of the effect. Results According to Odom's criteria, 79% of the patients showed acceptable to excellent results and confirmed that denervation helped them to manage their daily lives better. The average pain reduction in the responder group was 57% with an average duration of 13.4 months. Conclusion In this retrospective study, we could demonstrate the practicability and effectiveness of endoscopic SIJ denervation in the treatment of SIJ pain using only one incision for three levels on each side. Further studies should investigate if this procedure is more effective than percutaneous RF.

Consensus practice guidelines on interventions for cervical spine (facet) joint pain from a multispecialty international working group

BackgroundThe past two decades have witnessed a surge in the use of cervical spine joint procedures including joint injections, nerve blocks and radiofrequency ablation to treat chronic neck pain, yet many aspects of the procedures remain controversial.MethodsIn August 2020, the American Society of Regional Anesthesia and Pain Medicine and the American Academy of Pain Medicine approved and charged the Cervical Joint Working Group to develop neck pain guidelines. Eighteen stakeholder societies were identified, and formal request-for-participation and member nomination letters were sent to those organizations. Participating entities selected panel members and an ad hoc steering committee selected preliminary questions, which were then revised by the full committee. Each question was assigned to a module composed of 4–5 members, who worked with the Subcommittee Lead and the Committee Chairs on preliminary versions, which were sent to the full committee after revisions. We used a modified Delphi method whereby the questions were sent to the committee en bloc and comments were returned in a non-blinded fashion to the Chairs, who incorporated the comments and sent out revised versions until consensus was reached. Before commencing, it was agreed that a recommendation would be noted with >50% agreement among committee members, but a consensus recommendation would require ≥75% agreement.ResultsTwenty questions were selected, with 100% consensus achieved in committee on 17 topics. Among participating organizations, 14 of 15 that voted approved or supported the guidelines en bloc, with 14 questions being approved with no dissensions or abstentions. Specific questions addressed included the value of clinical presentation and imaging in selecting patients for procedures, whether conservative treatment should be used before injections, whether imaging is necessary for blocks, diagnostic and prognostic value of medial branch blocks and intra-articular joint injections, the effects of sedation and injectate volume on validity, whether facet blocks have therapeutic value, what the ideal cut-off value is for designating a block as positive, how many blocks should be performed before radiofrequency ablation, the orientation of electrodes, whether larger lesions translate into higher success rates, whether stimulation should be used before radiofrequency ablation, how best to mitigate complication risks, if different standards should be applied to clinical practice and trials, and the indications for repeating radiofrequency ablation.ConclusionsCervical medial branch radiofrequency ablation may provide benefit to well-selected individuals, with medial branch blocks being more predictive than intra-articular injections. More stringent selection criteria are likely to improve denervation outcomes, but at the expense of false-negatives (ie, lower overall success rate). Clinical trials should be tailored based on objectives, and selection criteria for some may be more stringent than what is ideal in clinical practice.

Intraoperative study of the functional perforasome - an experimental model

Background and aims. The aim of this study is to find the most suitable protocol based on an animal experimental model, through the use of a fluorescent dye, determining also its minimal concentration needed to stain the skin after arterial injection, in order to be evidence the functional perforasome by visual examination. Methods. Methylene blue solution was used in order to determine the territory vascularized by one perforator on fresh cadavers in many studies which introduced, as a final result, the concept of perforasome. One of the most frequent complications of perforator flaps is partial flap necrosis which could be avoided by correctly assessing pre-operatively the functional perforasome surface. Two groups of seven rats were used in order to establish a proper surgical protocol to evaluate the functional perforasome in vivo by injecting the dye. Also, the minimal concentration for methylene blue was experimentally determined. Results. The direct injection into the femoral artery of the proper concentration of dye, 1mM for methylene blue and the clamping of all the branches except the medial branch of the superficial epigastric artery is a reliable model to study the functional perforasome. Conclusions. Our study demonstrates that the intraoperative assessment with fluorescent dye of the functional perforasome by intra-arterial injection of methylene blue is an easy, affordable and very efficient method to reduce the number of partial necrosis of the perforator flaps.

A new ocular motor sign in acute vestibular syndrome: Is HINTS plus enough?

A 66-year-old hypertensive and diabetic male presented with acute vestibular syndrome for three days. HINTS plus examination was performed. The horizontal head impulse test was positive on the left side. Video oculography showed centripetal nystagmus on gaze testing in the dark and test of skew was negative. There was no new hearing loss on the finger rub test. On neurological examination, he had severe postural instability and saccadic smooth pursuit. Radio-imaging studies were conducted to rule out the possibility of stroke. CT brain showed infarction in the territory of the medial branch of the right posterior inferior cerebellar artery. MRI brain confirmed the diagnosis. Thus, posterior circulation stroke can present with acute vestibular syndrome mimicking acute unilateral vestibulopathy. However, the presence of associated neurological symptoms like gait ataxia, centripetal nystagmus and vascular risk factors pointed towards a central cause. Clinical evaluation suggesting a peripheral lesion should never be taken in isolation and needs to be correlated with other associated signs. We describe centripetal nystagmus without fixation as a new oculomotor sign in acute vestibular syndrome.