Extremity Pain Research Articles

Comparison of methotrexate and methylprednisolone as addition to antifibrotic therapy in progressive pulmonary fibrosis due to COVID-19.

Post-covid pulmonary fibrosis (PCPF) is an essential cause of hypoxic respiratory failure, especially in patients with severe COVID-19 infection. In our study, we aimed to compare the effectiveness of methylprednisolone and methotrexate treatments in patients diagnosed with PCPF and in whom progression was observed despite nintedanib treatment. Methods: Forty-eight patients diagnosed with PCPF between April 2022 and February 2023 were followed up in our study. Progressive pulmonary fibrosis was observed in 18 of these patients despite nintedanib treatment. Nintedanib + methylprednisolone treatment was started in Group 1 patients, and nintedanib + methotrexate treatment was started in Group 2 patients, and after three months, a respiratory function test (PFT), 6-minute walk test (6MWT), saturation, pulse, and side effect levels were compared. In comparing the groups at the end of the 3rd month, the change in PFT parameters was higher in Group 2 patients than in Group 1 patients. However, there was no statistically significant difference. However, the increase in fingertip saturation, 6MWT levels, and decrease in pulse levels were statistically significantly different in Group 2 patients compared to Group 1 patients (p=0.001 for all). It was observed that complaints of muscle and joint pain, weight gain, and atrophy in peripheral extremities in Group 1 patients were statistically significantly higher than in Group 2 patients (p=0.001, 0.002, 0.001, respectively). Methotrexate can be used as an alternative to methylprednisolone in PCPF due to its low side effect profile and its effectiveness in PFT, 6MWT, and saturation levels.

Pain in Children and Adolescents with Cerebral Palsy: A Cross-sectional Survey Study.

This study aims to investigate the prevalence, intensity, and location of pain in children and adolescents with cerebral palsy (CP) and analyze pain-related symptoms and participation restrictions. Children and adolescents aged 2 to 16 years diagnosed with CP were invited to participate in a pain survey. The questionnaire was based on the German Pain Questionnaire for Children, Adolescents and Parents (DSF-KJ). It was administered to children (2-11 years) by their caregivers, while adolescents (12-16 years) were asked to complete the questionnaire themselves or with the help of their caregivers. Fifty-seven of 133 children and adolescents with CP (43%) reported having pain in the past 12 months, of whom 17 (30%) reported chronic pain. Patients with Gross Motor Function Classification System (GMFCS) IV-V reported more frequent pain (p = 0.003) and higher pain intensity (p = 0.011). Lower extremity pain was the most common. Twenty-three percent of participants with pain did not receive any treatment. Pain often restricted participation, specifically by reducing sports activity in patients with GMFCS I-III, focusing attention on patients with GMFCS IV-V, and activities with the family in both GMFCS level categories. Pain is common in children and adolescents with CP and frequently restricts their participation. Therefore, it must be consistently recorded and addressed during the consultation. The goal of treatment should be not only to reduce pain but above all to increase participation.

Paroxysmal extreme pain disorder associated with a mutation in SCN9A gene – Case report and own experiences

IntroductionPain is an unpleasant sensory and emotional experience, influenced by various factors. Paroxysmal extreme pain disorder (PEPD) is a rare genetic condition characterized by sudden bouts of pain accompanied by autonomic symptoms.Material, methods and aimThis manuscript presents the case of a 9-year-old boy with paroxysmal extreme pain syndrome and provides a review of the literature. Additionally, a genealogical analysis of the boy’s family was conducted to determine the total number of affected family members. The clinical data included an analysis of genetic tests to identify the mutation confirming PEPD.Result and conclusionA mutation in the SCN9A gene causes the disease, and due to the small number of patients worldwide (around 500, according to literature reports), an effective method of preventing extreme pain attacks had not been established at the time of writing this manuscript. Based on information from scientific sources and the authors’ experiences, it can be firmly stated that various, often difficult-to-identify factors cause paroxysmal extreme pain. This syndrome necessitates further research and the exploration of effective treatment methods.

An osteopathic assessment of lower extremity somatic dysfunctions in runners.

Runners often experience acute/chronic pain due to pre-existing structural somatic dysfunction and/or acquired various overuse injuries of the lower extremity, specifically affecting the ligaments, tendons, muscles, and bones. Common structural and function dysfunctions include but are not limited to patellofemoral pain syndrome (PFPS), Achilles tendonitis, iliotibial band syndrome (ITBS), ligamentous and muscle tears, muscle sprains/strains, stress fractures, pes planus, plantar fasciitis, and shin splints. The purpose of this study is to assess the correlation between acute and chronic pain, overuse injuries, and observational and palpatory findings upon evaluation to establish common trends of somatic dysfunctions and determine possible etiology of the pain/injury. A total of 103 individuals were recruited (54.4% female, 45.6% male) aged 23-67 years old who consistently run at least 1 mile each week. They were categorized based on their weekly mileage- Novice (1-5 miles per week), Moderate (6-15), Advanced (15+)- with the intention to have a diversity of running types and to assess the data at various levels of commitment to running. The average was 7.8 miles/week with the range at 1 to 28 miles per week. The subjects included Touro students and individuals in the community. A history was collected through an anonymous survey on the individual's running habits, chronic/acute injuries, and any other relevant medical information. Data analyzing investigators were blinded to subjects' identifying information. Additionally, an osteopathic assessment was performed by two student investigators for reliability purposes and conducted under supervision by a board-certified osteopathic physician. Analysis of the data suggested an existing correlation between the number of somatic dysfunctions and years of running. A slight correlation was found between somatic dysfunctions and miles per week, sports injuries, time per week, and lower extremity pain. Finally, statistical correlations were also identified between the presence of pes planus and limb length discrepancy with three distinct muscular hypertonicities. Runners' pains and injuries of the lower extremity are complex, and injury treatment and prevention is equally multifaceted. An association was found between both pes planus and limb length discrepancy with lower extremity muscle hypertonicity, suggesting the interrelated nature of these somatic dysfunctions. The survey concluded that many runners continue to run in pain and/or after significant injury but do not necessarily capitalize on existing support such as fitted shoes, custom arches, and osteopathic treatment that may help to minimize their risk of or treat injury. The intention of the research is to bring awareness to practitioners to the most common somatic dysfunctions such that they can recommend runners to obtain gait analyses and/or osteopathic treatments, which may not only alleviate injuries faster but also prevent future injury.

Application of Solis fusion device in adjacent segment degeneration revision after anterior cervical discectomy bone grafting fusion

To observe the early clinical efficacy of the zero-remember cervical Solis fusion device in the treatment of adjacent segment degeneration(ASD) revision after anterior cervical discectomy and fusion(ACDF). A retrospective analysis was performed for 13 patients with adjacent spondylosis after anterior cervical discectomy bone graft fusion with Solis fusion device, including 5 males and 8 females, aging from 56 to 78 years old. The patients had intractable neck pain or superficial paresthesia of upper extremities before operation, and the effect of conservative treatment was not good. The operation time, intraoperative blood loss and postoperative complications were recorded. Before operation, 1 week postoperative and final follow-up, the visual analogue scale(VAS) and Japanese Orthopaedic Association(JOA) scores were used to assess clinical efficacy. X-ray and CT of the cervical spine were performed to measure and evaluate the height of the intervertebral space and intervertebral fusion. All patients were followed up from 18 to 36 months. All 13 patients successfully completed revision surgery with single gaps. The operation time was 63 to 93 min, the intraoperative blood loss was 15 to 83 ml. The pain VAS was reduced from 4 to 7 points before surgery to 1 to 3 points at 1 week and 1 to 2 points at the final follow-up. The height of the intervertebral space was increased from 5.2 to 7.2 mm before surgery to 6.4 to 8.0 mm at 1 week after surgery and 6.4 to 7.9 mm at the final follow-up. The JOA score was increased from 11 to 17 points before surgery to 13 to 17 points at 1 week after surgery and 16 to 17 points at the final follow-up visit. At the final follow-up, AP and lateral X-ray films of cervical spine showed homogeneous bone fusion of the Solis fusion. One patient developed transient left upper limb weakness after surgery, which recovered at follow-up, and all patients had no dysphagia, incision hematoma or infection, and displacement. The early clinical efficacy of Solis fusion device in the treatment of orthospondylosis after anterior cervical intervertebral fusion is satisfactory, and it has the advantages of less surgical trauma, adequate decompression, high osseointegration rate and fewer complications, which can provide a new option for minimally invasive treatment of orthospondylosis after cervical spine surgery.

Anterior Laparoscopic Approach Combined with Posterior Approach for Lumbosacral Neurolysis: A Case Report

Background and importance: Sacral fractures often lead to injuries of the lumbosacral nerve, which will cause tremendous damage to the patient’s motor and sensory functions. At present, the most commonly used surgical method is the posterior median approach, the extent and degree of neurolysis are often insufficient, so the effect of neurolysis is not well, and the functional recovery of patients after operation is often incomplete. Clinical presentation: The patient was a 17-year-old male who accidentally fell from a height and landed on his hip. The main clinical feature of the patient was persistent radiating pain in the right lower extremity with right lower limb sensorimotor disorder. The results of the X-ray examination indicated a sacral fracture and a right pubic fracture. After the injury, the patient underwent pelvic internal fixation surgery within 72 hours. Then 6 months after the surgery, there was no significant improvement in right lower limb function, and the patient came to our hospital seeking treatment. Considering the severe lumbosacral plexus injury and the history of surgery, we performed an “Anterior surgery approach combined with posterior approach for lumbosacral neurolysis” for the patient, postoperative radiation pain disappeared completely, and there were significant improvements in the muscle strength of some muscles and sensory function. Conclusion: The relaxation of the lumbosacral plexus is usually performed through a single surgical approach, which has great limitations in the effect of relaxation. Here, we demonstrate a case in which posterior lumbar incision and anterior laparoscopic lumbosacral plexus neurolysis can benefit the patient, the lumbosacral nerve was released to a great extent. We aim to bring this case to the attention of our worldwide neurosurgical colleagues and share our surgical approach to assist those who may encounter this case in the future.

Bilateral lower extremity compartment syndrome after prolonged gynecological surgery in lithotomy position: a case report

BackgroundAcute compartment syndrome is a rare but serious complication following gynecological surgery in the lithotomy position, potentially resulting in permanent neuromuscular dysfunction or limb loss, making early recognition and prompt management essential.Case presentationA 41-year-old woman underwent a laparoscopic myomectomy for uterine fibroids, during which she was positioned in the high lithotomy and head-down position for 118 min. Six hours post-surgery, she experienced spasmodic pain and swelling in both lower extremities. Thirteen hours after surgery, her symptoms worsened, leading to the diagnosis of acute compartment syndrome in both legs. An emergency bilateral fasciotomy was performed, and the patient fully recovered within two months without any neuromuscular dysfunction.ConclusionsACS should be an important differential diagnosis for lower extremity pain after gynecologic surgery, especially with prolonged lithotomy positioning. Gynecologists should be vigilant for ACS signs and symptoms to prevent delayed diagnosis.

Spinal Cord Stimulation vs Medical Management for Chronic Back and Leg Pain

Chronic back and lower extremity pain is one of the leading causes of disability worldwide. Spinal cord stimulation (SCS) aims to improve symptoms and quality of life. To evaluate the efficacy of SCS therapies compared with conventional medical management (CMM). MEDLINE, Embase, and Cochrane Library were systematically searched from inception to September 2, 2022. Selected studies were randomized clinical trials comparing SCS therapies with sham (placebo) and/or CMM or standard treatments for adults with chronic back or leg pain who had not previously used SCS. Evidence synthesis estimated odds ratios (ORs) and mean differences (MDs) and their associated credible intervals (CrI) through bayesian network meta-analysis. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guideline for network meta-analyses was followed. The primary outcomes were pain-related end points, including pain intensity (measured by visual analog scale) and proportion of patients achieving at least 50% pain relief (responder rate) in the back or leg. Quality of life (measured by EQ-5D index score) and functional disability (measured by the Oswestry Disability Index score) were also considered. A total of 13 studies of 1561 patients were included in the network meta-analysis comparing conventional and novel SCS therapies with CMM across the 6 outcomes of interest at the 6-month follow-up. Both conventional and novel SCS therapies were associated with superior efficacy compared with CMM in responder rates in back (conventional SCS: OR, 3.00; 95% CrI, 1.49 to 6.72; novel SCS: OR, 8.76; 95% CrI, 3.84 to 22.31), pain intensity in back (conventional SCS: MD, -1.17; 95% CrI, -1.64 to -0.70; novel SCS: MD, -2.34; 95% CrI, -2.96 to -1.73), pain intensity in leg (conventional SCS: MD, -2.89; 95% CrI, -4.03 to -1.81; novel SCS: MD, -4.01; 95% CrI, -5.31 to -2.75), and EQ-5D index score (conventional SCS: MD, 0.15; 95% CrI, 0.09 to 0.21; novel SCS: MD, 0.17; 95% CrI, 0.13 to 0.21). For functional disability, conventional SCS was superior to CMM (MD, -7.10; 95% CrI, -10.91 to -3.36). No statistically significant differences were observed for other comparisons. This systematic review and network meta-analysis found that SCS therapies for treatment of chronic pain in back and/or lower extremities were associated with greater improvements in pain compared with CMM. These findings highlight the potential of SCS therapies as an effective and valuable option in chronic pain management.

Abstract 4147627: A Pharmacovigilance Study of Bempedoic Acid: Balancing Risks and Benefits

Introduction: Bempedoic acid has been approved by FDA since Feb 2020 as an adjunct to maximally tolerated statin therapy for the reduction of LDL-C, specifically in individuals afflicted by atherosclerotic cardiovascular disease (ASCVD) and heterozygous familial hypercholesterolemia (HeFH). Bempedoic acid is also a viable alternative for patients intolerant to statins. Most recently, it has been approved to use for primary prevention of hyperlipidemia, alone or in combination with a statin. It is important to study its side effect profile as it is anticipated to be used more frequentlynin the future. Methods: We explored reported adverse events (AEs) of bempedoic acid using FDA Adverse Event Reporting System (FAERS). A total of 1202 adverse effects were reported until March 31, 2024. 69.97% AEs were reported by healthcare professionals (HCPs), which were further analyzed. AEs were analyzed in men (32.53%) vs women (53.24%) and in three age groups of 18-64, 65-85, and >85 years. Results: A total of 586 (48.7%) events were serious adverse effects. Most common side effects were myalgia which included muscle pain, extremity pain and muscle spasm (25.04%), arthralgia including back pain and bone pain (18.47%), nausea (6.6%), headache(5.5%), gout (4.4%). Among the patients with adverse effects, 4.75% had cardiac side effects which included atrial fibrillation (12%), palpitation (29%), angina pectoris (18%), Myocardial Infarction (5%). Discussion: A thorough understanding of bempedoic acid's complex pharmacology empowers healthcare professionals to tailor treatment plans based on individual patient requirements. This enables informed decision-making in prescribing, optimizing dosage regimens, and mitigating potential adverse reactions. Most studies have been relatively short term in order to confirm the long term side effect profile. It would be beneficial to be cautious in using this medication for patients with above mentioned clinical conditions like myalgia, arthralgia, gout, rhabdomyolysis, atrial fibrillation, angina pectoris. Conclusion: Long term pharmacovigilance is needed to assess the safety profile of bempedoic acid over extended use. With the current increasing use of bempedoic acid, there is a need for more data on safety profiles. In future, further randomized trials are required to better assess the safety profile.

Predisposing factors for incomplete spontaneous recovery after Parsonage-Turner Syndrome.

Parsonage-Turner Syndrome (PTS) is a rare idiopathic brachial neuritis that classically presents with sudden onset upper extremity pain followed by upper limb weakness, sensory disruption, and muscle atrophy. We hypothesized that the type of antecedent event before symptom onset would determine the degree of spontaneous recovery after PTS. We retrospectively reviewed all patients who presented with PTS to a single tertiary referral center from January 2002 to December 2021. Each medical record was reviewed to exclude patients with any other identifiable neurologic etiology. The primary outcome was improved muscle strength measured by a modified British Medical Research Council (mBMRC) grading system. The spontaneous recovery cohort included patients with appreciable or full recovery (mBMRC 4 and 5). In contrast, patients with little to no recovery (mBMRC 0 to 3) were included in the incomplete recovery group. Antecedent events, demographic variables, affected upper extremity region, time between symptom onset and final visit, and presence of nerve surgery were analyzed. Two-tailed T-test and Fisher exact tests were used to compare continuous and categorical variables. Multivariable logistic regression was modeled to identify variables associated with spontaneous recovery. 100 patients with 144 extremities met the inclusion criteria. The average time from symptom onset to the final clinic visit was 3.5 years. 65 extremities (57.0%) spontaneously recovered without surgical intervention, whereas 49 extremities (43.0%) incompletely recovered. The spontaneous recovery cohort was younger (mean [SD] age, 47.4 [18.1] vs. 56.5 [18.7]; p = 0.02) and had fewer bilateral cases (count[%], 4 [6.5%] vs. 10 [26.3%]; p = 0.008). Multivariable logistic regression revealed that each year of increased age was associated with a 3% decreased chance of spontaneous recovery (OR[95%CI] 0.97[0.95, 0.99], p = 0.046). Bilateral involvement was associated with 93% decreased chance of recovery (OR[95%CI] 0.07[0.01, 0.39], p = 0.002), each additional muscle affected was associated with 10% decreased chance of recovery (OR[95%CI] 0.90[0.83, 0.97], p = 0.01), and traumatic antecedent events were associated with increased chance of recovery (OR[95%CI] 27.3[2.59, 287.5], p = 0.006). Younger patients with unilateral symptoms and fewer muscle involvement have a greater chance of spontaneous recovery after PTS. PTS precipitated by trauma may have better spontaneous recovery than those precipitated by other causes.

Chronic and Acute Pain and Adverse Economic Outcomes in a 9/11-Exposed Cohort.

The objective of this study was to determine the association between acute and chronic pain and various economic and quality-of-life outcomes. The study sample was drawn from the World Trade Center Health Registry. Both acute and chronic pain were measured in 2020-2021. Logistic regression models were constructed to determine the odds of several economic and quality-of-life variables: early retirement, low household income, decline in household income, quality of life, and not working due to health. Those who had extreme pain in the last four weeks that interfered with normal work had 3.12 (95% confidence interval (CI): 2.36, 4.39) times the odds of early retirement, 5.34 (95% CI: 3.47, 8.21) times the odds of having a household income below USD 50,000, 2.56 (95% CI: 1.51, 4.33) times the odds of having an income decrease, and 14.4 (95% CI: 11.3, 18.3) times the rate of poor health days compared to those with no pain. Similar results were found for chronic pain. The detrimental effects of pain may influence multiple facets of a patient's life, and both financial and overall well-being may diminish even several years after a pain diagnosis.

Ballooning and Bursting of Barrels and Pipes: A Rare Case of Suspected Vascular Ehlers–Danlos Disease

Vascular Ehler–Danlos disease (vEDS), a rare subtype of a rare disease, is a life-threatening disease, with an increased risk for spontaneous vascular or visceral rupture. These patients have fatal complications ranging from vascular aneurysms, dissection, and rupture of systemic vessels to frequent thromboembolic events, the common causes of death in these individuals with a shortened life span. In the present case, a 28-year-old male with history of shoulder dislocations and spontaneous colon perforation presented to the primary care clinic with right lower extremity swelling and pain. His history includes presentation to the emergency department with left lower leg swelling with compartment syndrome one year prior. A CT angiogram of lower extremities and abdomen revealed acute arterial extravasation of the left posterior tibial artery, indicating a ruptured aneurysm along with aneurysms of the splenic artery and left common iliac artery. He was treated with a saphenous vein graft, but was associated with post-operative complications that necessitated below-knee amputation. CT angiogram of his right leg revealed occlusion of the anterior tibial and peroneal arteries with aneurysms, and, ultimately, he was referred to a tertiary care center for aneurysm embolization. This case report emphasizes the frequent vascular complications encountered in vascular EDS patients, and thus advocates for close and regular monitoring for early referral and surgical management of their vascular anomalies. Finally, genetic counseling and screening of asymptomatic family members should be routinely implemented in these patients.

Culture, community, and cancer: understandings of breast cancer from a non-lived experience among women living in Soweto

BackgroundIndividual perceptions, socio-cultural beliefs and health system factors are key determinants of people’s health seeking behavior and are widely cited as the causes of delayed breast cancer diagnosis among women from structurally vulnerable settings. Asking: “how do women with a non-lived experience of cancer understand the disease and, what informs their health seeking behaviors?”, we qualitatively explored, individual, sociocultural and health system elements from a conceptual model derived from the Socioecological, Health Belief and Cancer Stigma Frameworks, to understand perspectives of breast cancer in a South African urban community setting.MethodsUsing a deductive approach and allowing new themes to emerge inductively, we investigated phenomenologically, breast cancer perceptions among 34 women from Soweto, Johannesburg (aged 35–74 years) in 6 Focus Group Discussions. We then conducted 20 follow-up semi-structured in-depth interviews to explore novel themes and suggestions for increasing breast cancer screening.ResultsFindings revealed some awareness of breast and other cancers, but confusion and gaps in understanding of the disease, resulting in socio-culturally influenced misperceptions of risks, causes, and outcomes following treatment of breast cancer. This fueled perceptions of profound fear and stigma against people with breast and other cancers. These findings together with participant perceptions of primary healthcare providers being unwelcoming, under-resourced, and insufficiently trained to deal with breast cancer, resulted in women reporting being reluctant to participating in screening/early detection care seeking behavior. Women only accessed primary care when experiencing extreme pain or ill-health. Participants suggested as solutions for future interventions, the need for sustained community engagement, harnessing existing clinic and community stakeholders and resources to provide clear and understandable breast cancer information and encouragement for screening uptake.ConclusionsHealth literacy gaps surrounding breast cancer fuels socio-culturally influenced misperceptions, fear, stigma, and fatalism among women from Soweto. Women perceive primary care providers of having insufficient knowledge, skills, and resources to provide effective breast cancer screening services. Participants suggested the need for greater community engagement involving primary clinics and existing community stakeholders working collaboratively. Clear, understandable, and consistent information about breast cancer must be regularly disseminated and communities must be regularly encouraged to utilize breast cancer screening services.

Post-procedural Brachial Neuritis: Clinical, Electrodiagnostic and Neuroimaging features.

Brachial neuritis is a monophasic condition affecting the brachial plexus and its branches, manifesting as acute shoulder and upper arm pain, followed by weakness and paresthesias. It can be triggered by antecedent events, including procedures such as surgery. Misdiagnosis and delay in diagnosis is common. Imaging is important to confirm the diagnosis of post-procedural brachial neuritis and exclude other etiologies. Clinical, electrodiagnostic, and neuroimaging features of patients with post-procedural brachial neuritis from a single quaternary care institution were identified and analyzed. Six (2 female) patients were identified with median age 62 (range 49-70) years. Antecedent procedures included 4 cervical spine surgeries, 1 rotator cuff repair, and 1 central venous catheter placement. Time to symptom onset ranged from 1-day to 2-weeks. The initial symptom for 5/6 patients was severe upper extremity pain followed by weakness. All patients had electrodiagnostic tests and MR neurography consistent with brachial neuritis. MR neurogram showed plexus and/or terminal branch abnormalities with associated muscular denervation edema. The C5 or C6 root, and/or upper trunk were always involved. The most common branches affected were the suprascapular, long thoracic, and axillary nerves. Hourglass constrictions of these nerves were seen in 3/6 patients. The average time to diagnosis was 3.4 (range 1.5-5) months. Post-procedural brachial neuritis is an underrecognized cause of acute upper extremity pain and weakness. MR neurography can exclude iatrogenic causes and document the presence of hourglass constrictions in affected nerves. Diagnostic neuroradiologists should be aware of this clinical entity and associated neuroimaging findings. HGC = hourglass constriction; EDX = electrodiagnostic; IRB = Institutional Review Board; ACDF = anterior cervical discectomy and fusion; NRS = Numerical Rating Scale; MUAP = motor unit action potential.

Brainstem hemorrhage associated with venous hypertensive myelopathy without dural arteriovenous fistula: illustrative case.

Venous hypertensive myelopathy (VHM), formerly known as "Foix-Alajouanine syndrome," is a spinal cord dysfunction caused by impaired perfusion of the spinal cord. Most cases are attributed to spinal dural arteriovenous fistulas (dAVFs), but there are scattered reports of VHM without concomitant dAVF. Furthermore, no cases of VHM associated with intracranial hemorrhage exist. A 68-year-old man with a history of hypertension presented with a sudden headache, proximal paresis of the left upper extremity, impaired pain and temperature sensation in the right upper extremity, dysphagia, and dysarthria. Computed tomography scans showed intraparenchymal hemorrhage in the left medulla oblongata and a linear, continuous high-density area extending from the medulla oblongata to the cervical spinal cord. Magnetic resonance images showed cervical spondylosis at the C5-6 and C6-7 levels, with high signal intensity changes from the medulla oblongata to the lower cervical cord on T2-weighted images. Cerebral angiography showed no abnormal vessels. Conservative treatment gradually improved symptoms and the high signal intensity areas. This case highlights intracranial hemorrhage occurring from extracranial causes and the possibility of VHM due to cervical spondylosis. When hemorrhagic lesions of the craniovertebral junction or spinal parenchymal lesions are encountered, the underlying pathology should be investigated thoroughly and systematically. https://thejns.org/doi/10.3171/CASE24441.

The occurrence of remitting seronegative symmetrical synovitis with pitting edema (RS3PE) after arthroplasty mimicking a periprosthetic joint infection: A case report and literature review.

As the elderly population grows, the number of joint arthroplasty surgeries is also increasing. Periprosthetic joint infection (PJI) is a postoperative complication that occurs in 1%-2% of the arthroplasties. Once it occurs, PJI is refractory to treatment. Similar symptoms of PJI, including joint synovitis and elevated body temperature, sometimes arise because of crystal arthritis, rheumatoid arthritis, or other inflammatory diseases. Precise diagnosis is essential for determining the optimal treatment strategy. An 81-year-old female patient with a history of bilateral knee arthroplasty presented with a high fever of 38 °C and was unable to walk due to swelling and pain in the bilateral lower extremities. Infectious conditions, such as cellulitis or PJI, were suspected. Imaging findings revealed bilateral knee joint synovitis with pitting edema around the lower extremities, and cultures of bilateral joint fluids were negative. No crystals were observed in the joint fluid. Laboratory data revealed highly elevated levels of inflammatory marker; however, antinuclear antibodies, including rheumatoid factor and cyclic citrullinated peptide, were not detected. Based on bilateral synovitis with pitting edema in the lower extremities, in addition to negative culture findings and normal antinuclear antibodies, the diagnosis of remitting seronegative symmetrical synovitis with pitting edema (RS3PE) was made. Steroid therapy was performed. The dose was gradually reduced, with the improvement of the symptoms. The inflammatory reaction promptly decreased and then normalized. With improved inflammation, the symptoms of pitting edema, pain in the bilateral lower extremities, and fluid effusion of the knee joints were reduced. She was able to walk without a cane, and her activities of daily living fully recovered. High fever and synovitis after joint arthroplasty do not necessarily indicate an infectious condition. Clinicians should be familiar with the occurrence of RS3PE, regardless of whether arthroplasty is performed.

Surgical Management of Thoracic Dorsal Arachnoid Webs: A 10-Year Single-Institution Experience

ObjectiveThoracic dorsal arachnoid webs are intradural membranes that may cause obstruction of CSF flow and spinal cord compression. While well-recognized, they are rare and there is a paucity of long-term data on their natural history and prognosis. We reviewed radiographic features, surgical indications, and pathologic specimens of patients diagnosed with focal thoracic dorsal arachnoid webs. MethodsA radiology database and surgical case logs were queried for thoracic arachnoid webs at a single hospital system for a ten-year period. A retrospective chart review was performed on identified cases. ResultsWe identified 127 patients with dorsal thoracic arachnoid webs. Arachnoid webs were radiographically classified into three morphologic types: Type 1 (54%) causing spinal cord deformity only, Type 2 (32%) producing cord deformity with myelomalacia, and Type 3 (14%) with cord deformity, myelomalacia, and syringomyelia. These arachnoid webs were commonly centered at the upper thoracic T4 segmental level. Forty-one cases (32%) required surgery, generally for thoracic myelopathy with gait instability (46%) and lower extremity numbness and pain (39%). In patients who underwent surgery, 79% experienced symptomatic improvement and 21% remained stable, after an average of 21 months follow-up evaluation. Surgical pathology revealed fibrous connective tissue (100%) with calcifications (26%) or inflammation (7%). ConclusionsThe majority in a large series of patients with dorsal arachnoid webs did not undergo surgical intervention, but those with myelomalacia and syrinx experienced radiographic and clinical deterioration without surgery. Surgery to treat symptomatic arachnoid webs results in significant clinical improvement with low surgical morbidity.

Relationship Between Stride Mechanics and Shoulder Distraction Force in Collegiate Softball Pitchers.

Softball pitchers experience high shoulder distraction forces, and increased stride lengths are associated with upper extremity pain. Therefore, it is important to consider the influence of stride mechanics on shoulder distraction force in softball pitchers. To determine the relationship between stride mechanics and shoulder distraction force in collegiate softball pitchers. Descriptive laboratory study. A total of 63 collegiate softball pitchers (age, 20.1 ± 1.3 years; height, 173.3 ± 7.4 cm; weight, 79.7 ± 11.7 kg) were included in this study. Each pitcher threw 3 maximum-effort fastballs for a strike, and kinematic data were collected using an electromagnetic tracking system with a sampling frequency of 100 Hz. A forward regression analysis was used to determine the relationship between stride parameters at foot contact (stride length, stride-foot progression angle, and stride-foot position) and shoulder distraction force. Regression analysis revealed a significant and positive relationship between stride length and shoulder distraction force (R 2 = 0.11; F(1, 61) = 7.338; P = .009), where stride length accounted for 11% of the variation in shoulder distraction force. Specifically, shoulder distraction force increased by 0.94 N/kg for every 10% increase in stride length normalized as a percentage of body height. A positive relationship was found between stride length and peak shoulder distraction force during the acceleration phase of the softball pitch. Alternatively, no relationship was found between the other stride parameters (stride position and stride-foot progression angle) and shoulder distraction force. Coaches should be aware of the potential negative implications of increasing stride length during softball pitching. Although prior research has shown that greater stride length may positively affect performance, this may also increase stress at the shoulder.

Lower urinary tract symptoms (LUTS) as a clinical feature of lumbar spinal stenosis (LSS): a prospective study with lumbar spine morphometry analysis

<p><strong>Aim</strong> To investigate clinical and morphometric characteristics of patients with lower urinary tract symptoms (LUTS) due to lumbar spinal stenosis (LSS).<br /><strong>Methods</strong> This study evaluated LSS patients using clinical assessments of motor, sensory, bladder, and bowel functions, and functional disability scores from the Oswestry Disability Index (ODI) and Swiss Spinal Stenosis Questionnaire (SSSQ). Morphometric analysis included MRI measurements of the anteroposterior diameter of the intervertebral disc and dural sac, and the modified Torg-Pavlov ratio (mTPR), with follow-up re-evaluations at 6 months.<br /><strong>Results</strong> Of 159 patients, 49 (30.8%) had LUTS and 110 (69.2%) were in the control group. LUTS patients had a significantly higher prevalence of neurogenic claudication (100% vs. 47.3%; p<0.001), lower back pain (93.9% vs. 77.3%; p=0.011), and lower extremity pain (57.1% vs. 34.5%; p=0.008). The LUTS group also had higher ODI (54.0 vs. 50.0; p=0.019) and SSSQ score (44.0 vs. 34.0; p<0.001). Morphometric analysis showed significantly lower mTPR in LUTS patients (median 0.31 vs. 0.45; p<0.001), with an AUC of 0.704 (95%CI 0.627-0.774). mTPR≤0.31 predicted surgical revision within 6 months (OR:3.4, CI: 1.2-9.8), motor deficiency (OR:2.1, 95%CI: 1.4-5.2), and persistent LUTS post-surgery (OR:4.5, 95%CI: 1.1-18.9). mTPR≤0.34 was associated with worse follow-up outcome, including increased ODI (β:3.2; 95%CI: 1.1-5.3; p=0.004) and SSSQ score (β:4.8; 95%CI:2.1-7.5).<br /><strong>Conclusion</strong> LUTS patients with LSS exhibit more severe symptoms and poorer outcome, with mTPR≤0.34 being a predictor of adverse clinical outcome and the need for surgical revision within 6 months.</p>

Unilateral Biportal Endoscopic Decompression for Thoracic Spinal Stenosis Secondary to Ossification of the Ligamentum Flavum

Ossification of the ligamentum flavum (OLF) in the thoracic spine is a cause of thoracic myelopathy that is more commonly found in East Asian populations (Koreans, Japanese, Chinese) than in others. Early diagnosis and sufficient surgical decompression can improve the functional prognosis for thoracic OLF. Surgical decompression is necessary and should be done as soon as the symptoms develop. There is a wide range of possible treatments, from standard open laminectomy to endoscopic decompression surgery. This video demonstrates the least invasive technique of decompressive laminectomy with bilateral decompression and removal of thoracic OLF through unilateral biportal endoscopic spinal surgery. The authors present the case of an 81-year-old male patient who presented with bilateral lower extremity weakness, numbness, pain, and ataxia. Magnetic resonance imaging and computed tomography scans of the whole spine showed the presence of OLF with severe spinal canal stenosis and a cord signal change at the T9–10 level. He underwent biportal endoscopic decompression and removal of thoracic OLF at T9–10. On the discharge day (postoperative day 7), motor power and pain had significantly improved. He could stand and independently ambulate with a walker.