Cryoneurolysis for Digital Neuralgia in Professional Baseball Players: A Case Series

ObjectiveWe describe a non-surgical approach to refractory digital neuralgia using cryoneurolysis in a series of 3 professional baseball players.BackgroundThumb injuries are common in baseball players and can sometimes be challenging to effectively manage. Depending on the injury, current treatments include anti-inflammatories, immobilization, physical therapy, corticosteroid injections, and/or surgery. A subset of patients, however, fail nonoperative management yet do not have a clear indication for surgery. Cryoneurolysis or cyroanalgesia is an FDA-approved form of neuromodulation, which has been used safely and effectively on a variety of peripheral nerves. The mechanism of action involves percutaneous introduction of a small probe under local anesthetic to nerve tissue using ultrasound guidance. The probe is then cooled to −88°C using nitrous oxide, which results in secondary Wallerian degeneration. Axonal and myelin regeneration occurs completely in 3–6 months.Design/MethodsVisualization of the superficial radial sensory and ulnar digital nerve were obtained under ultrasound. The skin was prepared in sterile fashion. A 22-gauge 1-½ inch needle was then advanced with ultrasound guidance, and local anesthetic was applied. Both treatment sites were marked with skin marker. Cryoneurolysis was employed using a 5 mm tip. 60-second treatment cycles were performed at each site. Each of the cycles resulted in a 5 × 7 mm lesion visible as hypoechoic signal.ResultsAll 3 players endorsed significant and prolonged relief and were able to return to an elite level of play.ConclusionsThis manuscript is subject to all of the limitations of a case series, and larger rigorous studies are needed to illuminate causal inferences. Novel, complex technologies may also be more susceptible to placebo effect. Nonetheless, we are able to report marked efficacy and safety from cryoneurolysis of the ulnar digital nerve and the superficial radial sensory nerve in a small group of elite baseball players with refractory digital neuralgia.

Assessment of Stability of MIMU Probes to Skin-Marker-Based Anatomical Reference Frames During Locomotion Tasks: Effect of Different Locations on the Lower Limb

Soft tissue artefacts (STAs) undermine the validity of skin-mounted approaches to measure skeletal kinematics. Magneto-inertial measurement units (MIMU) gained popularity due to their low cost and ease of use. Although the reliability of different protocols for marker-based joint kinematics estimation has been widely reported, there are still no indications on where to place MIMU to minimize STA. This study aims to find the most stable positions for MIMU placement, among four positions on the thigh, four on the shank, and three on the foot. Stability was investigated by measuring MIMU movements against an anatomical reference frame, defined according to a standard marker-based approach. To this aim, markers were attached both on the case of each MIMU (technical frame) and on bony landmarks (anatomical frame). For each MIMU, the nine angles between each versor of the technical frame with each versor of the corresponding anatomical frame were computed. The maximum standard deviation of these angles was assumed as the instability index of MIMU-body coupling. Six healthy subjects were asked to perform barefoot gait, step negotiation, and sit-to-stand. Results showed that (1) in the thigh, the frontal position was the most stable in all tasks, especially in gait; (2) in the shank, the proximal position is the least stable, (3) lateral or medial calcaneus and foot dorsum positions showed equivalent stability performances. Further studies should be done before generalizing these conclusions to different motor tasks and MIMU-body fixation methods. The above results are of interest for both MIMU-based gait analysis and rehabilitation approaches using wearable sensors-based biofeedback.

Clinical and Biomechanical Progression after Ankle Joint Distraction in a Young Adolescent Patient with Haemophilia

Ankle joint distraction (AJD) has been described to be a valuable joint-sparing alternative to arthrodesis or arthroplasty; however, clinical endpoints associated to this surgical intervention are lacking. The current case report describes clinical and biomechanical outcome measures of ankle joint distraction in a 14-year-old patient with severe haemophilia A. Because of persistent and incapacitating pain and the poor response to conservative and invasive treatment options, ankle joint distraction was performed in this 14-year-old patient using an external fixator encompassing two Ilizarov full rings in the tibia and a foot ring fixed to the foot by four K-wires. State-of-the-art medical imaging and non-invasive skin marker-based 3D multi-segment foot modelling were performed in a pre- and post-operative stage. From a structural viewpoint, this AJD was a success since it improved and stabilised the osteo-cartilaginous lesions of the ankle. Biomechanical outcome measures associated with the 18-month follow-up were found to be suboptimal, showing an early plantarflexion pattern at the ankle joint during midstance and a tendency towards increased power absorption at the midfoot with peak power absorption being almost two times higher when compared to boys of the same age. From a functional viewpoint, we observed a clear reduction in the patients’ physical activities until one year after AJD. Despite these functional and structural improvements, recurrent painful phenomena, including the development of a complex regional pain syndrome (CRPS) and a stress fracture of the third metatarsal bone, were observed which are probably related with the development of recurrent subchondral oedema.

Prevalence of Metabolic Syndrome in Urban South Indian Population

Because of changes in lifestyle, poor dietary habits, and obesity, the prevalence of non-communicable diseases such as hypertension, diabetes mellitus, and coronary artery disease is on the rise. The metabolic syndrome is a straightforward method for predicting the risk of diabetes and cardiovascular disease in the future. To compare the prevalence of metabolic syndrome in urban south Indian males and females and the prevalence of metabolic syndrome in various age groups above 20 years. To find out the most common metabolic abnormality among the study population and to find out specificity and sensitivity of any specific skin marker among the study population.

Spinal Palpation Error and Its Impact on Skin Marker-Based Spinal Alignment Measurement in Adult Spinal Deformity

Spinal alignment measurement in spinal deformity research has recently shifted from using mainly two-dimensional static radiography toward skin marker-based motion capture approaches, allowing three-dimensional (3D) assessments during dynamic conditions. The validity and accuracy of such skin marker-based methods is highly depending on correct marker placement. In this study we quantified, for the first time, the 3D spinal palpation error in adult spinal deformity (ASD) and compared it to the error in healthy spines. Secondly, the impact of incorrect marker placement on the accuracy of marker-based spinal alignment measurement was investigated. 3D, mediolateral and inferosuperior palpation errors for thoracolumbar and lumbar vertebral levels were measured on biplanar images by extracting 3D positions of skin-mounted markers and their corresponding anatomical landmarks in 20 ASD and 10 healthy control subjects. Relationships were investigated between palpation error and radiographic spinal alignment (lordosis and scoliosis), as well as body morphology [BMI and soft tissue (ST) thickness]. Marker-based spinal alignment was measured using a previously validated method, in which a polynomial is fit through the marker positions of a motion trial and which allows for radiograph-based marker position correction. To assess the impact of palpation error on spinal alignment measurement, the agreement was investigated between lordosis and scoliosis measured by a polynomial fit through, respectively, (1) the uncorrected marker positions, (2) the palpation error-corrected (optimal) marker positions, and (3) the anatomically corrected marker positions (toward the vertebral body), and their radiographic equivalents expressed as Cobb angles (ground truth), using Spearman correlations and root mean square errors (RMSE). The results of this study showed that, although overall accuracy of spinal level identification was similar across groups, mediolateral palpation was less accurate in the ASD group (ASDmean: 6.8 mm; Controlmean: 2.5 mm; p = 0.002). Significant correlations with palpation error indicated that determining factors for marker misplacement were spinal malalignment, in particular scoliotic deformity (r = 0.77; p < 0.001), in the ASD group and body morphology [i.e., increased BMI (rs = 0.78; p = 0.008) and ST thickness (rs = 0.66; p = 0.038)] in healthy spines. Improved spinal alignment measurements after palpation error correction, shows the need for radiograph-based marker correction methods, and therefore, should be considered when interpreting spinal kinematics.

Clinical spectrum of MTOR-related hypomelanosis of Ito with neurodevelopmental abnormalities

Purpose Hypomelanosis of Ito (HI) is a skin marker of somatic mosaicism. Mosaic MTOR pathogenic variants have been reported in HI with brain overgrowth. We sought to delineate further the pigmentary skin phenotype and clinical spectrum of neurodevelopmental manifestations of MTOR-related HI. Methods From two cohorts totaling 71 patients with pigmentary mosaicism, we identified 14 patients with Blaschko-linear and one with flag-like pigmentation abnormalities, psychomotor impairment or seizures, and a postzygotic MTOR variant in skin. Patient records, including brain magnetic resonance image (MRI) were reviewed. Immunostaining (n = 3) for melanocyte markers and ultrastructural studies (n = 2) were performed on skin biopsies. Results MTOR variants were present in skin, but absent from blood in half of cases. In a patient (p.[Glu2419Lys] variant), phosphorylation of p70S6K was constitutively increased. In hypopigmented skin of two patients, we found a decrease in stage 4 melanosomes in melanocytes and keratinocytes. Most patients (80%) had macrocephaly or (hemi)megalencephaly on MRI. Conclusion MTOR-related HI is a recognizable neurocutaneous phenotype of patterned dyspigmentation, epilepsy, intellectual deficiency, and brain overgrowth, and a distinct subtype of hypomelanosis related to somatic mosaicism. Hypopigmentation may be due to a defect in melanogenesis, through mTORC1 activation, similar to hypochromic patches in tuberous sclerosis complex.

Minimally invasive supratentorial neurosurgical approaches guided by Smartphone app and compass

The precise location in the scalp of specifically planned points can help to achieve less invasive approaches. This study aims to develop a smartphone app, evaluate the precision and accuracy of the developed tool, and describe a series of cases using the referred technique. The application was developed with the React Native framework for Android and iOS. A phantom was printed based on the patient's CT scan, which was used for the calculation of accuracy and precision of the method. The points of interest were marked with an "x" on the patient's head, with the aid of the app and a compass attached to a skin marker pen. Then, two experienced neurosurgeons checked the plausibility of the demarcations based on the anatomical references. Both evaluators marked the frontal, temporal and parietal targets with a difference of less than 5 mm from the corresponding intended point, in all cases. The overall average accuracy observed was 1.6 ± 1.0 mm. The app was used in the surgical planning of trepanations for ventriculoperitoneal (VP) shunts and for drainage of abscesses, and in the definition of craniotomies for meningiomas, gliomas, brain metastases, intracranial hematomas, cavernomas, and arteriovenous malformation. The sample consisted of 88 volunteers who exhibited the following pathologies: 41 (46.6%) had brain tumors, 17 (19.3%) had traumatic brain injuries, 16 (18.2%) had spontaneous intracerebral hemorrhages, 2 (2.3%) had cavernomas, 1 (1.1%) had arteriovenous malformation (AVM), 4 (4.5%) had brain abscesses, and 7 (7.9%) had a VP shunt placement. In cases approached by craniotomy, with the exception of AVM, straight incisions and minicraniotomy were performed. Surgical planning with the aid of the NeuroKeypoint app is feasible and reliable. It has enabled neurological surgeries by craniotomy and trepanation in an accurate, precise, and less invasive manner.