Spinal Interventions Research Articles

ID:15827 Virtually Simulated Fluoroscopic Training to Enhance Resident Procedural Skill and Neuromodulation Exposure During COVID-19 Pandemic

Residency training has faced substantial challenges during the COVID-19 pandemic. Understandably, interventional pain procedures have seen an associated reduction in case volume due to global healthcare recommendations, especially due to many interventional spine procedures being categorized as elective.

ID:15992 Sterile Abscess Discovered During Spinal Cord Stimulator (SCS) Implant

Spinal epidural abscess is a diagnosis that has become increasingly common with the rise of spinal interventions.1 We present a case of a sterile abscess discovered during surgical placement of SCS. A 56-year-old female presented with a past medical history including sleep apnea, pulmonary embolism, obesity, lupus, CREST syndrome, along with chronic intractable bilateral upper extremity radiculopathy along with chronic intractable lower back pain with bilateral lumbar radiculopathy. Her history is also significant for having had two lumbar surgical procedures.

Infrapedicular approach to CT-guided thermal ablation in the thoracic spine.

The aim of this study is to introduce the infrapedicular approach to CT-guided spine interventions, a specialized technique that can safely expand the scope of spine lesions amenable to treatment, and to document the feasibility in a variety of procedural scenarios to the extent possible with a retrospective case series. Data from 24 cases performed at a single institution over a 10-year period were retrospectively reviewed to assess the technical feasibility and safety profile of the technique. The infrapedicular approach enabled a technically satisfactory procedural result in 24 cases (mean age 63.9years, range 35-83years). Two peri-procedural complications occurred, including a small pneumothorax and a cerebrospinal fluid leak, both of which resolved with conservative treatment. No lasting injurious effects or additional complications were identified. The infrapedicular approach was found to be particularly useful in multiple technically challenging scenarios: it facilitates access to lesions in the inferior vertebral body, allows biopsy, cement augmentation, or ablation of high thoracic lesions difficult to treat due to limitations of steep angulation of fluoroscopy and CT scanners, and enables treatment of large lesions by using multiple overlapping probes.

Biomechanical Analysis of 3-Level Anterior Cervical Discectomy and Fusion Under Physiologic Loads Using a Finite Element Model

ObjectivePseudarthrosis and adjacent segment degeneration (ASD) are 2 common complications after multilevel anterior cervical discectomy and fusion (ACDF). We aim to identify the potential biomechanical factors contributing to pseudarthrosis and ASD following 3-level ACDF using a cervical spine finite element model (FEM). MethodsA validated cervical spine FEM from C2 to C7 was used to study the biomechanical factors in cervical spine intervention. The FEM model was used to simulate a 3-level ACDF with intervertebral spacers and anterior cervical plating with screw fixation from C4 to C7. The model was then constrained at the inferior nodes of the T1 vertebra, and physiological loads were applied at the top vertebra. The pure moment load of 2 Nm was applied in flexion, extension, and lateral bending. A follower axial force of 75 N was applied to reproduce the weight of the cranium and muscle force, was applied using standard procedures. The motion-controlled hybrid protocol was utilized to comprehend the adjustments in the spinal biomechanics. ResultsOur cervical spine FEM demonstrated that the cranial adjacent level (C3–4) had significantly more increase in range of motion (ROM) (+90.38%) compared to the caudal adjacent level at C7–T1 (+70.18%) after C4–7 ACDF, indicating that the cranial adjacent level has more compensatory increase in ROM than the caudal adjacent level, potentially predisposing it to earlier ASD. Within the C4–7 ACDF construct, the C6–7 level had the least robust fixation during fixation compared to C4–5 and C5–6, as reflected by the smallest reduction in ROM compared to intact spine (-71.30% vs. -76.36% and -77.05%, respectively), which potentially predisposes the C6–7 level to higher risk of pseudarthrosis. ConclusionBiomechanical analysis of C4–7 ACDF construct using a validated cervical spine FEM indicated that the C3–4 has more compensatory increase in ROM compared to C7–T1, and C6–7 has the least robust fixation under physiological loads. These findings can help spine surgeons to predicate the areas with higher risks of pseudarthrosis and ASD, and thus developing corresponding strategies to mitigate these risks and provide appropriate preoperative counseling to patients.

Dural Puncture During Spinal Cord Stimulator Lead Insertion: Analysis of Practice Patterns.

BackgroundSpinal cord stimulation (SCS) is an important modality for intractable pain not amenable to less conservative measures. During percutaneous SCS lead insertion, a critical step is safe access to the epidural space, which can be complicated by a dural puncture.ObjectivesIn this review, we present and analyze the practices patterns in the event of a dural puncture during a SCS trial or implantation.MethodsWe conducted a survey of the practice patterns regarding spinal cord stimulation therapy. The survey was administered to members of the Spine Intervention Society and American Society of Regional Anesthesia specifically inquiring decision making in case of inadvertent dural puncture during spinal cord stimulator lead insertion.ResultsA maximum of 193 responded to a question regarding dural punctures while performing a SCS trial and 180 responded to a question regarding dural punctures while performing a SCS implantation. If performing a SCS trial and a dural puncture occurs, a majority of physicians chose to continue the procedure at a different level (56.99%), followed by abandoning the procedure (27.98%), continuing at the same level (10.36%), or choosing another option (4.66%). Similarly, if performing a permanent implantation and a dural puncture occurs, most physicians chose to continue the procedure at a different level (61.67%), followed by abandoning the procedure (21.67%), continuing at the same level (10.56%), or choosing another option (6.11%).ConclusionsWhereas the goals of the procedure would support abandoning the trial but continuing with the permanent in case of inadvertent dural puncture, we found that decision choices were minimally influenced by whether the dural puncture occurred during the trial or the permanent implant. The majority chose to continue with the procedure at a different level while close to a quarter chose to abandon the procedure. This article sets a time stamp in practice patterns from March 20, 2020 to June 26, 2020. These results are based on contemporary SCS practices as demonstrated by this cohort, rendering the options of abandoning or continuing after dural puncture as reasonable methods. Though more data is needed to provide a consensus, providers can now see how others manage dural punctures during SCS procedures.

The interrater reliability of the novel Udby classification of Modic Changes: A first estimate

BackgroundModic change grading is heterogeneous, inconsistent, and lacks a single nomenclature across the published literature. A new method of Modic change classification has been established by Dr. Peter Udby which hopes to unify how Modic changes are classified while also adding grading of the cranial/caudal extent of the Modic change across the vertebral body from the respective endplate involved to best capture the clinically relevant information of Modic changes. MethodsTwenty magnetic resonance images of potential basivertebral nerve ablation candidates were independently reviewed by two board-certified and fellowship trained neuroradiologist and two board-certified and fellowship-trained interventional spine physiatrists for the presence and characterization of Modic changes using the newly described Udby classification. 100% agreement of all four reviewers of Modic change presence, Type, and Udby classification was required to be classified as agreement. There were 480 total data points each with 10 unique choices to compare across the four independent reviewers. ResultsThe kappa value of their agreement was 0.5899 (95% CI 0.4860–0.6939). ConclusionThis study, requiring unanimous agreement between 4 physicians in application of the Udby classification, demonstrated an interrater reliability score of 0.5899 (95% CI 0.4860–0.6939). While this figure provides a first estimate, larger scale research is necessary before definitive claims regarding the interrater agreement validity of the Udby characterization system may be made.

Peri-surgical Complications Related to Anterior Cervical Spine Surgery: Smith-Robinson Approach

The primary goal is to identify the genuine incidence of peri-surgical complications associated with anterior cervical spine surgery in a low-income country. The secondary goal is to identify any risk factors predisposed to these complications; Especially dysphagia, as it is the most common perioperative complication, and to clarify the prognosis of these complications, as well as their proper management. This is a retrospective case-control study, including 109 patients who underwent anterior cervical spine intervention from the right side in Tishreen University Hospital in Lattakia, Syria, during the period between 1-1-2018 and 15-12-2021. Data was collected regarding gender, age, diagnosis (radiculopathy or myelopathy), surgical procedure, number of levels, plate addition, smoking, diabetes mellitus, and peri-surgical complications occurred during surgery proceeding to the next 14 days of follow-up. Male: female ratio was (1.4:1), 30.3% of cases were from a grouping (41-50) years of age. Myelopathy consists 56% of cases, anterior cervical discectomy and fusion (ACDF) consist of 47.7% of procedures. Intervention at one level represented the highest percentage at 52% of cases. The peri-surgical complication rate was 12.8%; divided into dysphagia 6.4%, recurrent laryngeal nerve (RLN) injury, superficial infection 1.8% each, dural tear, compressive hematoma, and neurological deterioration 0.9% each. Plate addition, 3 or more levels of intervention, and (ACDF+P) or (ACCF) surgery are all determined to be risk factors for the development of perioperative dysphagia. The majority of peri-surgical complications of anterior cervical spine surgery are minor and can be managed conservatively with a good prognosis. Early recognition of these complications with appropriate management is of paramount importance for improving the outcomes. Plate addition, 3 or more levels of intervention, and (ACDF+P) or (ACCF) surgery are all determined to be risk factors for the development of perioperative dysphagia.

Mapping Pediatric Spinal Cord Development with Age.

Pediatric spinal cord morphometry has been relatively understudied because of non-optimal image quality due to the difficulty of spine imaging, rarity of post-mortem analysis, motion artifacts, and pediatric MR imaging research focus on understanding spinal injury or pathology. The pediatric brain has been comparatively well-studied with white matter (WM), gray matter (GM), and cerebrospinal fluid (CSF) differences observed with age and gender. Therefore, a greater understanding of pediatric cervical and thoracic spinal cord morphometry would be beneficial for developing clinically relevant cord growth models. We focused on retrospectively characterizing cervical and thoracic spinal cord growth and morphometry changes in a healthy pediatric population. High resolution multi-echo gradient echo (mFFE) images were acquired from pediatric spinal cord scans from 63 patients (mean: 9.24 years, range: 0.83-17.67 years). The mFFE scans were then registered to the template space for uniform viewing and analysis by using a customized semi-automatic processing pipeline involving Spinal Cord Toolbox (SCT). Jacobian control determinants were calculated, and subsequent WM, GM, dorsal column, lateral funiculi, and ventral funiculi scalar averaging was conducted. Random effects models were used to model age-related Jacobian scalar differences. Observing the growth of cord matter by patient age and vertebral level suggests that the upper cervical spinal cord, specifically C2-C3, and mid-thoracic spinal cord, T3-T8, grow faster than other cervical levels and thoracic levels, respectively. This knowledge will facilitate clinical decision making when considering spine interventions and conducting radiological analysis in children with cervical and thoracic spine abnormalities.

An assessment of the validity and responsiveness of the Numerical Rating Scale version of the Pain Disability Quality-Of-Life Questionnaire-Spine

The Numerical Rating Scale Version of the Pain Disability Quality-Of-Life Questionnaire-Spine (NRS PDQQ-S) is a six question compensate patient reported outcome measure designed for use in the field of minimally invasive interventional spine care. Although acceptable reliability, validity and responsiveness have been confirmed for the Visual Analog Scale version of the PDQQ-S in patients undergoing lumbosacral spine corticosteroid injections and radiofrequency neurotomy, the Numerical Rating Scale version has undergone limited psychometric assessment. The purposes of this study were to define the validity and responsiveness of the NRS PDQQ-S, and to do so in a cohort undergoing an emerging type of spine intervention (platelet rich plasma [PRP] injection). Prospectively gathered pre-and 6months post lumbosacral spine PRP injection(s) NRS PDQQ-S and Oswestry Disability Index (ODI) data were analyzed on 75 patients. NRS PDQQ-S construct validity was evaluated by calculating the correlation with the ODI. Internal responsiveness was estimated for both PDQQ-S and ODI by calculating the effect size (Cohen’s d). External responsiveness was estimated by calculating the correlation between the change scores of the NRS PDQQ-S and ODI. Strong statistically significant correlations were documented between the PDQQ-S and ODI questionnaires at pre-PRP injection (r ​= ​0.67; p<.0001) and 6 months post-PRP injection (r ​= ​0.82; p<.0001) supporting construct validity. Internal responsiveness was confirmed by large and comparable effect sizes for both the NRS PDQQ-S [1.1 (CI 0.8–1.4)] (1.1) and ODI [0.9 (CI 0.7–1.2)]. External responsiveness was confirmed by the strong correlation between the change scores of the NRS PDQQ-S and ODI [r ​= ​0.73 (p<.0001)]. This study supports the premise that the NRS PDQQ-S is a valid and responsive instrument that can be used to assess patients with low back pain who are treated with PRP injections.

AutoInFocus, a new paradigm for ultrasound-guided spine intervention: a multi-platform validation study.

Ultrasound-guided spine interventions often suffer from the insufficient visualization of key anatomical structures due to the complex shapes of the self-shadowing vertebrae. Therefore, we propose an ultrasound imaging paradigm, AutoInFocus (automatic insonification optimization with controlled ultrasound), to improve the key structure visibility. A phased-array probe is used in conjunction with a motion platform to image a controlled workspace, and the resulting images from multiple insonification angles are combined to reveal the target anatomy. This idea is first evaluated in simulation and then realized as a robotic platform and a miniaturized patch device. A spine phantom (CIRS) and its CT scan were used in the evaluation experiments to quantitatively and qualitatively analyze the advantages of the proposed method over the traditional approach. We showed in simulation that the proposed system setup increased the visibility of interspinous space boundary, a key feature for lumbar puncture guidance, from 44.13 to 67.73% on average, and the 3D spine surface coverage from 14.31 to 35.87%, compared to traditional imaging setup. We also demonstrated the feasibility of both robotic and patch-based realizations in a spine phantom study. This work lays the foundation for a new imaging paradigm that leverages redundant and controlled insonification to allow for imaging optimization of the complex vertebrae anatomy, making it possible for high-quality visualization of key anatomies during ultrasound-guided spine interventions.

Systematic Review: Applications of Intraoperative Ultrasonography in Spinal Surgery

As a result of increased practicality and decreased costs and radiation, interest has increased in intraoperative ultrasonography (iUS) in spinal surgery applications; however, few studies have provided a robust overview of its use in spinal surgery. We synthesize findings of existing literature on use of iUS in navigation, pedicle screw placement, and identification of anatomy during spinal interventions. PRISMA guidelines were used in this systematic review. Studies were identified through PubMed, Scopus, and Google Scholar databases using the search string. Abstracts mentioning iUS in spine applications were included. On full-text review, exclusion criteria were implemented, including outdated studies or those with weak topic relevance or statistical power. On elimination of duplicates, multireviewer screening for eligibility, and citation search, 44 articles were analyzed. Navigation using iUS is safe, effective, and economical. iUS registration accuracy and success are within clinically acceptable limits for image-guided navigation. Pedicle screw instrumentation with iUS is precise, with a favorable safety profile. Anatomic landmarks are reliably identified with iUS, and surgeons are overwhelmingly successful in neural or vascular tissue identification with iUS modalities, including standard B mode, Doppler, and contrast-enhanced ultrasonography. iUS use in traumatic reduction of fractures properly identifies anatomic structures, intervertebral disc space, and vasculature. iUS eliminates radiation, decreases costs, and provides sufficient accuracy and reliability in identification of anatomic and neurovascular structures in various spinal surgery settings.

Single-dose antibiotic prophylaxis compared with multiple-dose protocol in clean pediatric neurosurgical interventions: a nonrandomized, historically controlled equivalence trial.

Guidelines recommend antimicrobial prophylaxis (AMP) preoperatively for "clean" spinal and cranial surgeries, while dose and timing remain controversial. The use of multiple-dose AMP for such surgeries is under debate in the pediatric context. In this clinical study, the authors aimed to compare single-dose with multiple-dose prophylactic antibiotic usage in cranial and spinal neurosurgical interventions of pediatric patients. All neurosurgical patients aged 28 days to 18 years who underwent surgery at a single tertiary center were assessed. Three cohorts (noninstrumented clean spinal, noninstrumented cranial, and instrumented cranial interventions), each of which comprised two 50-patient arms (i.e., single-dose AMP and multiple-dose AMP), were included after propensity score-matched retrospective sampling and power analysis. Records were examined for surgical site infections. Using a previously published meta-analysis as the prior and 80% acceptance of equivalence (margin of OR 0.88-1.13), logistic regression was carried out for the total cohort and each subcohort and adjusted for etiology by consideration of multiple-dose AMP as reference. The overall sample included 300 age- and sex-matched patients who were evenly distributed in 3 bi-arm cohorts. There was no statistical intercohort difference based on etiology or type of operation (p < 0.05). Equivalence analysis revealed nondiscriminating results for the total cohort (adjusted OR 0.65, 95% CI 0.27-1.57) and each of the subcohorts (noninstrumented clean spinal, adjusted OR 0.65, 95% CI 0.12-3.44; noninstrumented cranial, adjusted OR 0.52, 95% CI 0.14-2.73; and instrumented cranial, adjusted OR 0.68, 95% CI 0.13-3.31). No significant benefit for multiple-dose compared with single-dose AMPs in any of the pediatric neurosurgery settings could be detected. Since unnecessary antibiotic use should be avoided as much as possible, it seems that usage of single-dose AMP is indicated.

A proposed nomenclature for spinal imaging and interventional procedural reporting

ObjectiveTo develop precise universal standard interventional spine nomenclature for reporting procedural details and anatomy. MethodsThere is no comprehensive nomenclature of spinal imaging anatomy that can be used for anatomical and procedural reporting. Given this critical lack of unifying terminology, a system of nomenclature was developed de novo by expert consensus, based upon clinical needs, and previously published reports. ResultsNomenclature for anatomical and spine procedural reporting for interlaminar and transforaminal approaches was developed using zones in each view. Separate nomenclature for medial branch procedural reporting and discs and vertebral body location and procedural reporting is also presented. ConclusionThere is a need for a unified anatomical location reporting system in interventional spine. The first step is the development of a precise, simple, and intuitive nomenclature, as reported here. The second is ratification followed by dissemination and adoption in clinical practice.

Technical Report of Color Doppler Ultrasonography-Assisted Lumbar Spinal Interventions.

Ultrasonography (US) has recently been used more frequently during interventions involving the lumbar spine. However, physicians who are more familiar with musculoskeletal US targeting muscles, tendons, and nerves may find it challenging to perform US-guided lumbar spine interventions using only bony landmarks. This study described the use of color Doppler US for the visualization of the lumbar spinal blood supply to identify vascular landmarks in addition to bony landmarks and thus more easily and accurately perform lumbar spine interventions.

Virtual reality for procedural education: Lumbar medial branch radiofrequency neurotomy

Virtual reality (VR) simulation is an emerging tool in medical education. Simulation conducted in VR can reproduce procedural scenarios and allow for immersive interaction with anatomic models. This has the potential to improve understanding of anatomy and concepts relevant to interventional procedures.Here, we present a “proof-of-concept” modeling of lumbar thermal radiofrequency neurotomy through cost-effective, commercially available VR hardware and software. With this technology, we can demonstrate key fluoroscopic views and needle trajectories based on specific recommendations from Spine Intervention Society guidelines. Furthermore, the learner can manipulate the model in multiple 3-dimensional axes to visualize anatomy relevant to key fluoroscopic views. Finally, the content can be exported by recording a live casting stream, thus offering an approach for future content creation and collaboration.VR technology is an emerging educational modality that offers immersive and interactive features that may offer advantages to traditional visual teaching modalities.

Contralateral and Lateral Views: Analysis of the Technical Aspects of Spinal Cord Stimulator Lead Insertion.

BackgroundSpinal cord stimulation (SCS) is an established treatment modality for neuropathic pain. The critical part of this technique is safe access to the epidural space for lead placement. There have been innovations in radiological views, improving access to the epidural space.ObjectivesThis study analyzes the adoption of these technical advantages in daily practiceMethodsWe conducted a survey of members in the Spine Intervention Society and American Society of Regional Anesthesia in regard to the practice patterns in SCS therapy. Here we present our findings regarding the use of contralateral oblique (CLO) and lateral views as well direct upper thoracic or cervicothoracic access for SCS lead insertionResultsA total of 195 unique responses were received between March 20, 2020 and June 26, 2020. Forty-five percent of respondents “always used” the lateral view technique while 15% “always used” CLO view for SCS lead insertion. Overall, sixty-five percent of respondents used the CLO view with varying frequency. Cervical and upper thoracic approach for cervical SCS lead placement is always or often used by 66.8% of the respondents.ConclusionsA depth view (CLO or lateral) is always used by only 45 - 60% of the respondents and CLO view has been rapidly adopted in clinical practice for SCS lead insertion. Direct cervicothoracic and upper thoracic is the preferred approach for cervical lead placement by the majority.

The MOTION Study: A Randomized Controlled Trial with Objective Real-World Outcomes for Lumbar Spinal Stenosis Patients Treated with the mild® Procedure: One-Year Results.

ObjectiveThe purpose of this study is to provide Level-1 objective, real-world outcome data for patients with lumbar spinal stenosis suffering from neurogenic claudication secondary to hypertrophic ligamentum flavum.DesignThe MOTION Study is a prospective, multicenter, randomized controlled trial comparing the mild® Procedure (minimally invasive lumbar decompression; Vertos Medical, Aliso Viejo, CA, USA) as a first-line therapy in combination with nonsurgical conventional medical management (CMM) vs CMM alone as the active control.MethodsPatients in the test group received the mild Procedure at baseline. Both the mild+CMM group and the control group were allowed unrestricted access to conventional real-world therapies. Patient-reported outcomes included the Oswestry Disability Index, the Zurich Claudication Questionnaire, and the Numeric Pain Rating Scale. A validated Walking Tolerance Test, the incidence of subsequent lumbar spine interventions, and the occurrence of adverse events were used to measure objective outcomes.ResultsSixty-nine patients in each group were analyzed at 1-year follow-up. No device- or procedure-related adverse events were reported in either group. Results from all primary and secondary outcome measures showed statistical significance in favor of mild+CMM.ConclusionsOne-year results of this Level-1 study demonstrated superiority of mild+CMM over CMM alone for patients with lumbar spinal stenosis who were suffering from neurogenic claudication secondary to hypertrophic ligamentum flavum. Use of the validated Walking Tolerance Test to objectively measure increased ability to walk without severe symptoms provided evidence of statistically significantly better outcomes for mild+CMM than for CMM alone. With no reported device or procedure-related adverse events, the long-standing safety profile of the mild Procedure was reaffirmed. mild is a safe, durable, minimally invasive procedure that has been shown to be effective as an early interventional therapy for patients suffering from symptomatic lumbar spinal stenosis.

The effect of patient satisfaction scores on physician clinical decision making: A possible factor driving utilization of opioid prescriptions, magnetic resonance imaging, and interventional spine procedures

ObjectiveTo survey the effect of patient satisfaction scores on pain physicians’ medical decision making, with an emphasis on resource utilization. DesignEmail-based Survey. MethodsSetting & Subjects: A 23-question survey was approved for dissemination to membership of a medical society and emailed to all members. The survey was also available online and via a promoted QR code. ResultsAn email with link to the survey was viewed 1,116 times, and clicked on 223 times, with 75 members completing the survey online once the link was clicked. Thirty-three additional physicians directly accessed the survey online and completed it. Seventy-seven percent of physicians reported that patient satisfaction scores were tracked by their institution and were used as a consideration in financial compensation (22%) or performance review (36%). Over half of the physicians surveyed reported feeling that satisfaction scores would decline if they did not order MRI imaging, prescribe opioids or provide work restrictions/disability. Thirty percent reported to have performed a spine injection due to concern about patient satisfaction scores. Twenty-one reported that they had prescribed an opioid medication because of this concern. Lastly 25% and 24% have filled out disability paperwork or provided a disability parking placard respectively. ConclusionsOver half of physicians surveyed reported having ordered physical therapy, MRIs, opioid medications, spine injections, or provided disability documentation over concern about how providing or not providing such things impacts patient satisfaction scores. This may be an unintended consequence of the current emphasis placed on patient satisfaction scores.

Ultrasound-guided cervical facet joint injections

Cervical facet joints are a common cause of chronic neck pain. Radiofrequency neurotomy is a validated treatment technique for cervical facet joint pain, but the role of intra-articular injections is less clear. Ultrasound guidance can be used to inject the cervical facet joints. Given that the accuracy of any injection technique is likely to affect treatment outcomes, it would be useful to know the accuracy of ultrasound-guided cervical facet joint injections. The primary purpose of this study was to determine the accuracy of ultrasound-guided cervical facet joint injections using a lateral technique. The secondary purpose was to describe the technique. Cohort study of ultrasound-guided cervical facet joint injections performed by an experienced spine and ultrasound interventionist, as assessed by contrast dye arthrography at a community interventional spine practice. Sixty joints in 36 patients with facet mediated pain. Accuracy of ultrasound-guided injections as determined by the percent of fluoroscopic contrast dye patterns interpreted to be intra-articular by the operator and an independent imaging specialist. Confidence intervals were determined using binomial "exact" and normal approximation to the binomial calculations. Ultrasound using a long-axis or in-plane approach was used to guide a needle into a facet joint, followed by injection of contrast dye and a lateral fluoroscopic image. The dye pattern was interpreted by the operator. Depending on the pattern, local anesthetic and corticosteroid were injected. The patient was asked whether their neck pain had resolved. If not resolved, another joint was selected and the process was repeated. At the end of the study, all of the contrast patterns were interpreted independently by the imaging specialist. Funding was through a 501(c)(3) foundation without any commercial or sponsorship interests. The accuracy of ultrasound-guided cervical facet joint injections using the lateral technique ranged from 92% to 98% depending on the criteria used to confirm an intra-articular contrast pattern (95% CI: 0.82-0.97 to 0.91-1.0, and 0.85-0.99 to 0.95-1.00). The distribution of injections was C2-3 (22%), C3-4 (40%), C4-5 (33%) and C5-6 (5%). Cervical facet joint injections can be performed with a high degree of accuracy using a lateral ultrasound-guided technique. As with fluoroscopy-guided cervical facet joint injections, the technique requires a careful approach and a high degree of skill.

Painful Legs and Moving Toes

Painful Legs and Moving Toes syndrome (PLMT) is a rare neurological movement disorder characterized by involuntary and irregular movements of one or more toes, often together, with moderate to severe diffuse pain at the foot and leg. It can appear on one or both sides and in the upper limbs as well as lower limbs. The etiology of PLMT is still unclear; therefore, the main symptoms of PLMT, including pain in limbs as well as involuntary movements of toes, can be treated only symptomatically, and the outcomes are often unsatisfactory. Central or peripheral nerve injuries have been assumed to be the possible causes of irregular involuntary movements, often accompanied by chronic pain; however, its etiology is unknown in most cases. The management of PLMT is very difficult because of its rare prevalence and obscure pathogenesis, and there have been no clear guidelines for the treatment of PLMT. Oral medications (e.g., GABAergic agents, benzodiazepines, antiepileptics, antidepressants, atypical antipsychotics, beta-blockers, corticosteroids, cannabis, calcitonin, and analgesics) and several therapeutic interventions (e.g., local botulinum neurotoxin-A injection, spinal cord stimulation, anesthetic, and surgical interventions) have been recommended, based on individual experiences from several cases. Its etiology, pathogenesis, and effective treatments should be further discussed.